- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,819.70 / $2,187.76
| Facility | | $602.56 | $1,819.70 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,187.76
| Professional | | $1,548.82 | $1,548.82 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $1,122.02 / $1,318.26
| Facility | | $549.54 | $1,122.02 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $645.65 / $645.65
| Professional | | $575.44 | $645.65 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $1,548.82 / $1,737.80
| Facility | | $100.00 | $1,548.82 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $512.86 / $1,071.52
| Facility | | $416.87 | $512.86 | $1,071.52 |