- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $958.33 / $3,511.25 / $7,720.55
| Facility | | $958.33 | $3,511.25 | $7,720.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.10 / $958.33 / $1,466.46
| Professional | | $885.10 | $958.33 | $1,466.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.57 / $1,202.85 / $2,453.86
| Professional | | $1,082.57 | $1,202.85 | $2,453.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.54 / $2,154.40 / $3,023.48
| Professional | | $1,118.54 | $2,154.40 | $3,023.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.69 / $2,345.33 / $2,345.33
| Professional | | $1,056.69 | $2,345.33 | $2,345.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.47 / $1,424.02 / $2,970.01
| Professional | | $833.47 | $1,424.02 | $2,970.01 |