- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $927.25 / $1,083.57 / $1,747.76
| Facility | | $927.25 | $1,083.57 | $1,747.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.45 / $848.93 / $1,773.76
| Professional | | $672.45 | $848.93 | $1,773.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.00 / $3,597.38 / $3,597.38
| Professional | | $887.00 | $3,597.38 | $3,597.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.40 / $58.40 / $58.40
| Professional | | $58.40 | $58.40 | $58.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,930.50 / $3,930.50 / $3,930.50
| Facility | | $3,930.50 | $3,930.50 | $3,930.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,791.90 / $3,597.38 / $3,597.38
| Professional | | $1,791.90 | $3,597.38 | $3,597.38 |