- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $798.38 / $1,778.82 / $2,489.91
| Facility | | $798.38 | $1,778.82 | $2,489.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.00 / $798.38 / $798.38
| Professional | | $297.00 | $798.38 | $798.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,940.71 / $3,034.83 / $4,722.57
| Facility | | $1,940.71 | $3,034.83 | $4,722.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.51 / $291.51 / $291.51
| Professional | | $291.51 | $291.51 | $291.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $798.38 / $798.38 / $966.04
| Facility | | $798.38 | $798.38 | $966.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $753.66 / $753.66 / $753.66
| Professional | | $753.66 | $753.66 | $753.66 |