- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,288.25 / $3,090.30
| Facility | | $912.01 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $933.25 / $1,513.56
| Professional | | $549.54 | $933.25 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,230.27 / $2,398.83
| Facility | | $1,000.00 | $1,230.27 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $812.83 / $1,380.38
| Professional | | $537.03 | $812.83 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $588.84 / $758.58
| Facility | | $331.13 | $588.84 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $2,344.23
| Professional | | $1,230.27 | $1,230.27 | $2,344.23 |