- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $8,128.31 / $17,378.01
| Facility | | $741.31 | $8,128.31 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,348.96 / $1,949.84
| Professional | | $870.96 | $1,348.96 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,096.48 / $1,445.44
| Professional | | $891.25 | $1,096.48 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,174.90
| Professional | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $5,011.87 / $7,585.78
| Facility | | $190.55 | $5,011.87 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,318.26 / $1,862.09
| Professional | | $870.96 | $1,318.26 | $1,862.09 |