- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $2,344.23
| Facility | | $512.86 | $512.86 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $891.25 / $2,344.23
| Professional | | $60.26 | $891.25 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $2,754.23
| Facility | | $1,862.09 | $2,630.27 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,630.27 / $2,691.53
| Professional | | $2,137.96 | $2,630.27 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $2,187.76
| Facility | | $512.86 | $512.86 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,202.26
| Facility | | $1,047.13 | $1,047.13 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,348.96 / $3,890.45
| Professional | | $1,202.26 | $1,348.96 | $3,890.45 |