- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $914.72 / $914.72 / $1,687.37
| Facility | | $914.72 | $914.72 | $1,687.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.37 / $1,035.85 / $1,529.62
| Professional | | $740.37 | $1,035.85 | $1,529.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.20 / $2,254.92 / $2,480.53
| Professional | | $1,854.20 | $2,254.92 | $2,480.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.27 / $2,032.45 / $2,571.54
| Professional | | $1,189.27 | $2,032.45 | $2,571.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $914.72 / $1,488.12 / $1,828.38
| Facility | | $914.72 | $1,488.12 | $1,828.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.91 / $1,855.21 / $6,040.95
| Professional | | $1,011.91 | $1,855.21 | $6,040.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.74 / $1,855.21 / $2,191.63
| Professional | | $1,133.74 | $1,855.21 | $2,191.63 |