- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $836.03 / $836.03 / $913.44
| Facility | | $836.03 | $836.03 | $913.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.55 / $851.52 / $1,564.80
| Professional | | $820.55 | $851.52 | $1,564.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.17 / $1,672.44 / $1,672.44
| Professional | | $1,107.17 | $1,672.44 | $1,672.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $953.44 / $1,395.53 / $1,395.53
| Facility | | $953.44 | $1,395.53 | $1,395.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.74 / $1,018.74 / $1,395.53
| Professional | | $1,018.74 | $1,018.74 | $1,395.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,003.41 / $9,370.62 / $11,238.98
| Facility | | $3,003.41 | $9,370.62 | $11,238.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,357.28 / $11,357.28 / $13,769.33
| Professional | | $11,357.28 | $11,357.28 | $13,769.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $618.04 / $907.73 / $1,278.89
| Professional | | $618.04 | $907.73 | $1,278.89 |