- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,487.78 / $1,871.13 / $5,653.56
| Facility | | $1,487.78 | $1,871.13 | $5,653.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,487.78 / $1,871.13 / $5,653.56
| Facility | | $1,487.78 | $1,871.13 | $5,653.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.78 / $1,123.68 / $1,401.38
| Professional | | $840.78 | $1,123.68 | $1,401.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $830.00 / $830.00 / $830.00
| Facility | | $830.00 | $830.00 | $830.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.74 / $1,210.09 / $1,567.60
| Professional | | $1,067.74 | $1,210.09 | $1,567.60 |