- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $808.02 / $808.02 / $932.33
| Facility | | $808.02 | $808.02 | $932.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.02 / $828.16 / $946.44
| Professional | | $808.02 | $828.16 | $946.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,366.10 / $2,366.10 / $2,366.10
| Facility | | $2,366.10 | $2,366.10 | $2,366.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.40 / $1,086.33 / $2,378.23
| Professional | | $1,052.40 | $1,086.33 | $2,378.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.53 / $1,395.53 / $1,741.86
| Facility | | $1,395.53 | $1,395.53 | $1,741.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.74 / $1,018.74 / $1,982.49
| Professional | | $1,018.74 | $1,018.74 | $1,982.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,315.76 / $1,892.88 / $3,075.93
| Professional | | $1,315.76 | $1,892.88 | $3,075.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $696.75 / $889.85 / $1,483.09
| Professional | | $696.75 | $889.85 | $1,483.09 |