- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,412.54 / $8,511.38
| Facility | | $977.24 | $1,412.54 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,412.54 / $1,621.81
| Professional | | $977.24 | $1,412.54 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,659.59 / $2,951.21
| Facility | | $977.24 | $1,659.59 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,511.89 / $3,019.95
| Professional | | $1,479.11 | $2,511.89 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,862.09 / $3,311.31
| Professional | | $1,479.11 | $1,862.09 | $3,311.31 |