- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $886.25 / $886.25 / $2,278.92
| Facility | | $886.25 | $886.25 | $2,278.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.25 / $886.25 / $1,190.10
| Professional | | $886.25 | $886.25 | $1,190.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.76 / $2,551.13 / $2,848.66
| Professional | | $1,905.76 | $2,551.13 | $2,848.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.00 / $1,455.00 / $2,136.01
| Professional | | $1,455.00 | $1,455.00 | $2,136.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $759.64 / $962.21 / $2,278.92
| Facility | | $759.64 | $962.21 | $2,278.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.70 / $1,519.28 / $2,532.14
| Professional | | $645.70 | $1,519.28 | $2,532.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.75 / $1,291.39 / $2,152.32
| Professional | | $531.75 | $1,291.39 | $2,152.32 |