- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,311.31 / $6,309.57
| Facility | | $933.25 | $3,311.31 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,047.13 / $1,479.11
| Professional | | $933.25 | $1,047.13 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,412.54 / $1,862.09
| Professional | | $1,348.96 | $1,412.54 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $3,311.31 / $7,585.78
| Facility | | $870.96 | $3,311.31 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,148.15 / $2,290.87
| Facility | | $1,000.00 | $1,148.15 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,348.96 / $1,621.81
| Facility | | $1,202.26 | $1,348.96 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $794.33 / $1,348.96
| Professional | | $562.34 | $794.33 | $1,348.96 |