- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,230.27 / $1,230.27
| Facility | | $660.69 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $660.69 / $1,698.24
| Professional | | $616.60 | $660.69 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,258.93 / $2,344.23
| Facility | | $794.33 | $1,258.93 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $524.81 / $1,000.00
| Professional | | $416.87 | $524.81 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |