- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.46 / $7,019.76 / $7,019.76
| Facility | | $588.46 | $7,019.76 | $7,019.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.46 / $779.79 / $1,322.25
| Professional | | $588.46 | $779.79 | $1,322.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.72 / $1,747.47 / $2,517.46
| Professional | | $1,194.72 | $1,747.47 | $2,517.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.15 / $1,692.40 / $2,671.13
| Professional | | $901.15 | $1,692.40 | $2,671.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.46 / $1,032.35 / $1,755.01
| Facility | | $588.46 | $1,032.35 | $1,755.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.21 / $1,870.24 / $5,137.00
| Professional | | $1,050.21 | $1,870.24 | $5,137.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.21 / $1,858.87 / $2,310.46
| Professional | | $1,050.21 | $1,858.87 | $2,310.46 |