- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $795.12 / $795.12 / $2,041.53
| Facility | | $795.12 | $795.12 | $2,041.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.12 / $981.09 / $2,041.53
| Professional | | $795.12 | $981.09 | $2,041.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.19 / $2,454.19 / $2,454.19
| Facility | | $2,454.19 | $2,454.19 | $2,454.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.51 / $1,124.51 / $2,454.19
| Professional | | $1,124.51 | $1,124.51 | $2,454.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,408.48 / $1,408.48 / $1,806.72
| Facility | | $1,408.48 | $1,408.48 | $1,806.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.19 / $1,282.71 / $1,621.98
| Professional | | $1,028.19 | $1,282.71 | $1,621.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.76 / $1,963.35 / $3,190.45
| Professional | | $1,364.76 | $1,963.35 | $3,190.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $849.02 / $1,224.36 / $1,530.46
| Professional | | $849.02 | $1,224.36 | $1,530.46 |