- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $8,511.38
| Facility | | $891.25 | $891.25 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $891.25 / $2,137.96
| Professional | | $812.83 | $891.25 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,949.84 / $2,344.23
| Professional | | $1,659.59 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $2,754.23
| Professional | | $1,318.26 | $1,905.46 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,096.48 / $1,819.70
| Facility | | $891.25 | $1,096.48 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,584.89 / $6,606.93
| Professional | | $933.25 | $1,584.89 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $14,125.38
| Facility | | $1,819.70 | $2,041.74 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,584.89 / $2,137.96
| Professional | | $933.25 | $1,584.89 | $2,137.96 |