- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $805.10 / $2,012.75 / $8,689.02
| Facility | | $805.10 | $2,012.75 | $8,689.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.10 / $1,184.86 / $1,291.20
| Professional | | $805.10 | $1,184.86 | $1,291.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,484.88 / $2,243.94 / $4,783.59
| Facility | | $1,484.88 | $2,243.94 | $4,783.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,595.01 / $1,989.97 / $2,767.73
| Professional | | $1,595.01 | $1,989.97 | $2,767.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $531.66 / $531.66 / $8,702.00
| Facility | | $531.66 | $531.66 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.01 / $911.44 / $1,549.44
| Professional | | $638.01 | $911.44 | $1,549.44 |