- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $987.51 / $2,468.77 / $10,657.60
| Facility | | $987.51 | $2,468.77 | $10,657.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.51 / $1,453.31 / $1,583.74
| Professional | | $987.51 | $1,453.31 | $1,583.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,821.30 / $2,356.96 / $6,284.49
| Facility | | $1,821.30 | $2,356.96 | $6,284.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.25 / $2,440.82 / $3,394.79
| Professional | | $1,304.25 | $2,440.82 | $3,394.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.25 / $1,304.25 / $8,702.00
| Facility | | $1,304.25 | $1,304.25 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.25 / $1,304.25 / $1,304.25
| Professional | | $1,304.25 | $1,304.25 | $1,304.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $721.38 / $1,117.93 / $1,909.80
| Professional | | $721.38 | $1,117.93 | $1,909.80 |