- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $716.06 / $1,223.00 / $2,250.00
| Facility | | $716.06 | $1,223.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.36 / $716.06 / $716.06
| Professional | | $446.36 | $716.06 | $716.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $866.47 / $1,051.50 / $1,414.61
| Facility | | $866.47 | $1,051.50 | $1,414.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.34 / $497.39 / $865.76
| Professional | | $455.34 | $497.39 | $865.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.00 / $850.00 / $1,349.00
| Facility | | $241.00 | $850.00 | $1,349.00 |