- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $2,344.23
| Facility | | $912.01 | $912.01 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $1,548.82
| Professional | | $912.01 | $912.01 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,630.27 / $2,951.21
| Professional | | $1,905.46 | $2,630.27 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,905.46
| Professional | | $1,513.56 | $1,513.56 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,548.82 / $6,165.95
| Facility | | $912.01 | $1,548.82 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $2,238.72
| Professional | | $549.54 | $660.69 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $1,318.26 / $1,905.46
| Professional | | $549.54 | $1,318.26 | $1,905.46 |