- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $581.30 / $581.30 / $1,492.55
| Facility | | $581.30 | $581.30 | $1,492.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.30 / $730.39 / $1,492.55
| Professional | | $581.30 | $730.39 | $1,492.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,794.25 / $1,794.25 / $1,794.25
| Facility | | $1,794.25 | $1,794.25 | $1,794.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.22 / $822.12 / $1,794.25
| Professional | | $808.22 | $822.12 | $1,794.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.50 / $870.50 / $1,320.89
| Facility | | $870.50 | $870.50 | $1,320.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.47 / $870.50 / $1,185.81
| Professional | | $635.47 | $870.50 | $1,185.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.77 / $1,435.40 / $2,332.53
| Professional | | $997.77 | $1,435.40 | $2,332.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.72 / $671.35 / $1,118.91
| Professional | | $620.72 | $671.35 | $1,118.91 |