- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $663.16 / $663.16 / $1,702.71
| Facility | | $663.16 | $663.16 | $1,702.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.16 / $821.64 / $1,702.71
| Professional | | $663.16 | $821.64 | $1,702.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,046.88 / $2,046.88 / $2,046.88
| Facility | | $2,046.88 | $2,046.88 | $2,046.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.84 / $1,450.68 / $2,055.33
| Professional | | $925.84 | $1,450.68 | $2,055.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $963.22 / $963.22 / $1,506.88
| Facility | | $963.22 | $963.22 | $1,506.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $703.15 / $963.22 / $1,352.80
| Professional | | $703.15 | $963.22 | $1,352.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.26 / $1,637.50 / $2,660.94
| Professional | | $1,138.26 | $1,637.50 | $2,660.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.15 / $769.04 / $1,281.73
| Professional | | $602.15 | $769.04 | $1,281.73 |