- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $1,230.27 / $2,570.40
| Facility | | $524.81 | $1,230.27 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,041.74 / $3,890.45
| Professional | | $1,548.82 | $2,041.74 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,162.28
| Professional | | $2,570.40 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $1,479.11 / $8,709.64
| Facility | | $537.03 | $1,479.11 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $831.76 / $12,302.69
| Professional | | $741.31 | $831.76 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,258.93 / $1,778.28
| Facility | | $1,096.48 | $1,258.93 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $831.76 / $1,230.27
| Professional | | $741.31 | $831.76 | $1,230.27 |