- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $1,230.27 / $8,511.38
| Facility | | $223.87 | $1,230.27 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $223.87 / $1,230.27
| Professional | | $223.87 | $223.87 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $676.08 / $2,398.83
| Facility | | $223.87 | $676.08 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,995.26 / $3,019.95
| Professional | | $1,288.25 | $1,995.26 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,995.26 / $2,818.38
| Professional | | $1,230.27 | $1,995.26 | $2,818.38 |