- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $836.47 / $1,032.19 / $2,272.56
| Facility | | $836.47 | $1,032.19 | $2,272.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $1,032.19
| Professional | | $836.47 | $836.47 | $1,032.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $357.00 / $943.24 / $1,610.00
| Facility | | $357.00 | $943.24 | $1,610.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.54 / $343.54 / $477.42
| Professional | | $343.54 | $343.54 | $477.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,552.63 / $1,814.37 / $2,783.29
| Facility | | $1,552.63 | $1,814.37 | $2,783.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $360.74 / $360.74
| Professional | | $360.74 | $360.74 | $360.74 |