- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $692.57 / $692.57 / $1,778.22
| Facility | | $692.57 | $692.57 | $1,778.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $692.57 / $961.95 / $1,778.22
| Professional | | $692.57 | $961.95 | $1,778.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.66 / $2,137.66 / $2,137.66
| Facility | | $2,137.66 | $2,137.66 | $2,137.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,175.08 / $1,315.88 / $2,608.67
| Professional | | $1,175.08 | $1,315.88 | $2,608.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,222.54 / $1,222.54 / $1,573.68
| Facility | | $1,222.54 | $1,222.54 | $1,573.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.45 / $892.45 / $2,539.13
| Professional | | $892.45 | $892.45 | $2,539.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.73 / $1,710.13 / $2,778.96
| Professional | | $1,188.73 | $1,710.13 | $2,778.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.47 / $976.08 / $1,504.11
| Professional | | $902.47 | $976.08 | $1,504.11 |