- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $943.34 / $1,337.77 / $3,218.18
| Facility | | $943.34 | $1,337.77 | $3,218.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $574.08 / $721.87 / $1,193.33
| Professional | | $574.08 | $721.87 | $1,193.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $742.78 / $1,223.04 / $2,534.00
| Facility | | $742.78 | $1,223.04 | $2,534.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $568.40 / $568.40 / $1,044.17
| Professional | | $568.40 | $568.40 | $1,044.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $731.65 / $954.84 / $1,073.89
| Facility | | $731.65 | $954.84 | $1,073.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,247.00 / $5,247.00 / $5,247.00
| Professional | | $5,247.00 | $5,247.00 | $5,247.00 |