- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,819.70 / $3,162.28
| Facility | | $912.01 | $1,819.70 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,090.30 / $3,801.89
| Facility | | $1,380.38 | $3,090.30 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,023.29 / $1,174.90
| Professional | | $933.25 | $1,023.29 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,819.70 / $3,162.28
| Facility | | $1,584.89 | $1,819.70 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,162.28 / $3,467.37
| Professional | | $3,090.30 | $3,162.28 | $3,467.37 |