- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $3,388.44
| Facility | | $354.81 | $354.81 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $1,548.82 / $1,905.46
| Professional | | $354.81 | $1,548.82 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,818.38
| Facility | | $2,089.30 | $2,089.30 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,630.27
| Professional | | $1,737.80 | $1,737.80 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.13 / $1,548.82 / $3,630.78
| Facility | | $89.13 | $1,548.82 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,949.84
| Facility | | $1,737.80 | $1,737.80 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $1,949.84
| Professional | | $812.83 | $1,174.90 | $1,949.84 |