- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $936.06 / $936.06 / $2,403.40
| Facility | | $936.06 | $936.06 | $2,403.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.06 / $1,300.14 / $2,403.40
| Professional | | $936.06 | $1,300.14 | $2,403.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,889.21 / $2,889.21 / $2,889.21
| Facility | | $2,889.21 | $2,889.21 | $2,889.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,507.96 / $1,526.81 / $3,347.66
| Professional | | $1,507.96 | $1,526.81 | $3,347.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,119.51 / $2,119.51 / $2,126.96
| Facility | | $2,119.51 | $2,119.51 | $2,126.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.24 / $1,927.83 / $2,183.10
| Professional | | $1,547.24 | $1,927.83 | $2,183.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,606.66 / $2,311.37 / $3,755.97
| Professional | | $1,606.66 | $2,311.37 | $3,755.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.38 / $1,544.40 / $1,930.50
| Professional | | $1,167.38 | $1,544.40 | $1,930.50 |