- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $5,495.41 / $7,762.47
| Facility | | $758.58 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $912.01 / $2,570.40
| Professional | | $758.58 | $912.01 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,122.02 / $1,380.38
| Professional | | $1,023.29 | $1,122.02 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,202.26 / $2,344.23
| Professional | | $831.76 | $1,202.26 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $870.96 / $2,041.74
| Professional | | $831.76 | $870.96 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $7,943.28 / $26,915.35
| Facility | | $3,311.31 | $7,943.28 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,122.02 / $2,290.87
| Professional | | $812.83 | $1,122.02 | $2,290.87 |