- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $983.83 / $983.83 / $2,526.06
| Facility | | $983.83 | $983.83 | $2,526.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.83 / $1,328.84 / $2,526.06
| Professional | | $983.83 | $1,328.84 | $2,526.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,036.67 / $3,036.67 / $3,036.67
| Facility | | $3,036.67 | $3,036.67 | $3,036.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.87 / $1,376.42 / $3,036.67
| Professional | | $1,367.87 | $1,376.42 | $3,036.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,654.54 / $1,654.54 / $2,235.52
| Facility | | $1,654.54 | $1,654.54 | $2,235.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.81 / $1,566.65 / $2,001.24
| Professional | | $1,207.81 | $1,566.65 | $2,001.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,688.66 / $2,429.34 / $3,947.67
| Professional | | $1,688.66 | $2,429.34 | $3,947.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.53 / $1,136.22 / $1,893.70
| Professional | | $1,050.53 | $1,136.22 | $1,893.70 |