- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $814.62 / $1,890.53 / $8,791.75
| Facility | | $814.62 | $1,890.53 | $8,791.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.62 / $1,152.77 / $1,306.47
| Professional | | $814.62 | $1,152.77 | $1,306.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,502.43 / $2,270.55 / $4,840.14
| Facility | | $1,502.43 | $2,270.55 | $4,840.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.91 / $2,013.50 / $2,800.45
| Professional | | $1,075.91 | $2,013.50 | $2,800.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.38 / $192.38 / $8,702.00
| Facility | | $192.38 | $192.38 | $8,702.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,921.28 / $1,921.28 / $1,921.28
| Facility | | $1,921.28 | $1,921.28 | $1,921.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.54 / $922.21 / $1,567.76
| Professional | | $645.54 | $922.21 | $1,567.76 |