- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $835.20 / $1,081.84 / $1,495.01
| Facility | | $835.20 | $1,081.84 | $1,495.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.06 / $843.30 / $1,112.45
| Professional | | $817.06 | $843.30 | $1,112.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,001.02 / $1,001.02 / $1,001.02
| Facility | | $1,001.02 | $1,001.02 | $1,001.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.45 / $1,502.90 / $2,155.28
| Professional | | $1,112.45 | $1,502.90 | $2,155.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,725.37 / $4,752.43 / $4,925.70
| Facility | | $1,725.37 | $4,752.43 | $4,925.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,826.31 / $5,826.31 / $7,595.10
| Professional | | $5,826.31 | $5,826.31 | $7,595.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.89 / $1,308.77 / $1,308.77
| Professional | | $1,177.89 | $1,308.77 | $1,308.77 |