- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,238.72
| Facility | | $870.96 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,023.29 / $1,905.46
| Professional | | $794.33 | $1,023.29 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $8,709.64 / $11,748.98
| Facility | | $7,413.10 | $8,709.64 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $1,445.44
| Professional | | $812.83 | $1,174.90 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $1,000.00 / $1,513.56
| Professional | | $457.09 | $1,000.00 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,630.78 / $5,370.32
| Facility | | $1,122.02 | $3,630.78 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $870.96 / $1,380.38
| Professional | | $630.96 | $870.96 | $1,380.38 |