- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $762.61 / $762.61 / $1,958.06
| Facility | | $762.61 | $762.61 | $1,958.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.61 / $1,059.24 / $1,958.06
| Professional | | $762.61 | $1,059.24 | $1,958.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,353.86 / $2,353.86 / $2,353.86
| Facility | | $2,353.86 | $2,353.86 | $2,353.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,293.94 / $1,448.96 / $2,872.52
| Professional | | $1,293.94 | $1,448.96 | $2,872.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,346.19 / $1,346.19 / $1,732.86
| Facility | | $1,346.19 | $1,346.19 | $1,732.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.72 / $1,346.19 / $1,526.54
| Professional | | $982.72 | $1,346.19 | $1,526.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.95 / $1,883.09 / $3,060.02
| Professional | | $1,308.95 | $1,883.09 | $3,060.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.56 / $1,174.31 / $1,738.35
| Professional | | $841.56 | $1,174.31 | $1,738.35 |