- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.32 / $5,632.06 / $6,683.92
| Facility | | $402.32 | $5,632.06 | $6,683.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $4,972.50
| Professional | | $402.32 | $402.32 | $4,972.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,493.06 / $2,164.52 / $3,798.60
| Facility | | $1,493.06 | $2,164.52 | $3,798.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.93 / $1,054.93 / $1,054.93
| Professional | | $1,054.93 | $1,054.93 | $1,054.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $804.64
| Facility | | $402.32 | $402.32 | $804.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $1,666.22
| Professional | | $402.32 | $402.32 | $1,666.22 |