- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $868.00 / $868.00 / $868.00
| Facility | | $868.00 | $868.00 | $868.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,313.19 / $2,787.31 / $2,890.77
| Professional | | $2,313.19 | $2,787.31 | $2,890.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,815.72 / $2,815.72 / $2,815.72
| Facility | | $2,815.72 | $2,815.72 | $2,815.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.33 / $559.73 / $780.45
| Professional | | $349.33 | $559.73 | $780.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.45 / $1,420.64 / $3,776.26
| Professional | | $527.45 | $1,420.64 | $3,776.26 |