- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,819.70 / $2,511.89
| Facility | | $575.44 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $912.01 / $1,047.13
| Professional | | $575.44 | $912.01 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $5,623.41
| Facility | | $4,073.80 | $4,073.80 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $1,047.13
| Professional | | $794.33 | $794.33 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,981.07 / $8,511.38
| Facility | | $1,548.82 | $3,981.07 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,071.52 / $1,621.81
| Professional | | $851.14 | $1,071.52 | $1,621.81 |