- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $727.05 / $727.05 / $7,917.00
| Facility | | $727.05 | $727.05 | $7,917.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $468.32 / $727.05 / $2,356.86
| Professional | | $468.32 | $727.05 | $2,356.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $934.35 / $1,104.74 / $1,132.22
| Professional | | $934.35 | $1,104.74 | $1,132.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.38 / $1,169.96 / $1,471.14
| Professional | | $1,158.38 | $1,169.96 | $1,471.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $328.14 / $727.05 / $3,903.56
| Facility | | $328.14 | $727.05 | $3,903.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.51 / $560.87 / $796.23
| Professional | | $325.51 | $560.87 | $796.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.28 / $560.87 / $889.53
| Professional | | $249.28 | $560.87 | $889.53 |