- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $714.76 / $714.76 / $1,835.20
| Facility | | $714.76 | $714.76 | $1,835.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $714.76 / $881.94 / $1,835.20
| Professional | | $714.76 | $881.94 | $1,835.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,206.16 / $2,206.16 / $2,206.16
| Facility | | $2,206.16 | $2,206.16 | $2,206.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.78 / $1,006.20 / $2,206.16
| Professional | | $993.78 | $1,006.20 | $2,206.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,427.14 / $1,427.14 / $1,624.13
| Facility | | $1,427.14 | $1,427.14 | $1,624.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.81 / $1,396.47 / $1,469.95
| Professional | | $1,041.81 | $1,396.47 | $1,469.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.82 / $1,764.93 / $2,868.01
| Professional | | $1,226.82 | $1,764.93 | $2,868.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $646.34 / $825.47 / $1,375.79
| Professional | | $646.34 | $825.47 | $1,375.79 |