- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $766.63 / $766.63 / $1,968.38
| Facility | | $766.63 | $766.63 | $1,968.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.63 / $945.94 / $1,968.38
| Professional | | $766.63 | $945.94 | $1,968.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,366.26 / $2,366.26 / $2,366.26
| Facility | | $2,366.26 | $2,366.26 | $2,366.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.21 / $1,084.21 / $2,366.26
| Professional | | $1,084.21 | $1,084.21 | $2,366.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,530.70 / $1,530.70 / $1,741.99
| Facility | | $1,530.70 | $1,530.70 | $1,741.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.41 / $1,117.41 / $1,658.10
| Professional | | $1,117.41 | $1,117.41 | $1,658.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,315.85 / $1,893.01 / $3,076.14
| Professional | | $1,315.85 | $1,893.01 | $3,076.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.24 / $885.38 / $1,475.63
| Professional | | $693.24 | $885.38 | $1,475.63 |