- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $708.13 / $1,770.32 / $7,642.43
| Facility | | $708.13 | $1,770.32 | $7,642.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $708.13 / $1,042.15 / $1,135.68
| Professional | | $708.13 | $1,042.15 | $1,135.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,306.03 / $1,973.55 / $4,207.38
| Facility | | $1,306.03 | $1,973.55 | $4,207.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.26 / $1,750.28 / $2,434.36
| Professional | | $935.26 | $1,750.28 | $2,434.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $935.26 / $935.26 / $8,702.00
| Facility | | $935.26 | $935.26 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.26 / $935.26 / $935.26
| Professional | | $935.26 | $935.26 | $935.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $554.46 / $801.65 / $1,362.81
| Professional | | $554.46 | $801.65 | $1,362.81 |