- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,380.38 / $1,548.82
| Facility | | $758.58 | $1,380.38 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $616.60 / $1,380.38
| Professional | | $575.44 | $616.60 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,023.29 / $1,023.29
| Facility | | $977.24 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Professional | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $912.01
| Facility | | $691.83 | $691.83 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $457.09 / $1,698.24
| Professional | | $316.23 | $457.09 | $1,698.24 |