- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $884.47 / $884.47 / $2,274.35
| Facility | | $884.47 | $884.47 | $2,274.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.47 / $1,187.72 / $1,187.72
| Professional | | $884.47 | $1,187.72 | $1,187.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,901.93 / $2,546.01 / $2,842.94
| Professional | | $1,901.93 | $2,546.01 | $2,842.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,451.70 / $1,451.70 / $2,131.16
| Professional | | $1,451.70 | $1,451.70 | $2,131.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.12 / $960.28 / $2,274.35
| Facility | | $758.12 | $960.28 | $2,274.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.40 / $1,516.24 / $2,527.06
| Professional | | $644.40 | $1,516.24 | $2,527.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.67 / $1,288.80 / $2,148.00
| Professional | | $530.67 | $1,288.80 | $2,148.00 |