- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $774.01 / $774.01 / $1,987.32
| Facility | | $774.01 | $774.01 | $1,987.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.01 / $1,075.06 / $1,987.32
| Professional | | $774.01 | $1,075.06 | $1,987.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,389.03 / $2,389.03 / $2,389.03
| Facility | | $2,389.03 | $2,389.03 | $2,389.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,335.86 / $1,335.86 / $2,915.47
| Professional | | $1,335.86 | $1,335.86 | $2,915.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,366.32 / $1,366.32 / $1,758.75
| Facility | | $1,366.32 | $1,366.32 | $1,758.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.41 / $1,366.32 / $1,549.36
| Professional | | $997.41 | $1,366.32 | $1,549.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.52 / $1,986.44 / $3,440.20
| Professional | | $1,328.52 | $1,986.44 | $3,440.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.60 / $1,090.86 / $1,795.38
| Professional | | $1,008.60 | $1,090.86 | $1,795.38 |