- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $933.25 / $8,511.38
| Facility | | $891.25 | $933.25 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $912.01 / $1,621.81
| Professional | | $831.76 | $912.01 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,995.26 / $2,344.23
| Professional | | $1,621.81 | $1,995.26 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,737.80 / $2,884.03
| Professional | | $1,122.02 | $1,737.80 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,288.25 / $2,691.53
| Facility | | $891.25 | $1,288.25 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,513.56 / $6,760.83
| Professional | | $933.25 | $1,513.56 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,128.61 / $14,125.38
| Facility | | $4,677.35 | $5,128.61 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,584.89 / $2,137.96
| Professional | | $933.25 | $1,584.89 | $2,137.96 |