- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,819.70 / $2,818.38
| Facility | | $776.25 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,047.13 / $1,862.09
| Professional | | $512.86 | $1,047.13 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $25.12 / $50.12
| Professional | | $21.38 | $25.12 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $2,691.53 / $6,456.54
| Facility | | $724.44 | $2,691.53 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $4,786.30
| Professional | | $1,778.28 | $2,344.23 | $4,786.30 |