- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $889.75 / $13,573.67 / $13,573.67
| Facility | | $889.75 | $13,573.67 | $13,573.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.83 / $883.07 / $2,362.06
| Professional | | $814.83 | $883.07 | $2,362.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,712.19 / $1,883.50 / $2,208.51
| Professional | | $1,712.19 | $1,883.50 | $2,208.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.96 / $2,153.63 / $2,868.64
| Professional | | $1,077.96 | $2,153.63 | $2,868.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $889.75 / $1,098.30 / $1,512.58
| Facility | | $889.75 | $1,098.30 | $1,512.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.82 / $1,592.50 / $2,320.25
| Professional | | $909.82 | $1,592.50 | $2,320.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.82 / $1,566.19 / $2,001.60
| Professional | | $909.82 | $1,566.19 | $2,001.60 |