- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $914.16 / $914.16 / $2,347.17
| Facility | | $914.16 | $914.16 | $2,347.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.16 / $1,243.41 / $2,347.17
| Professional | | $914.16 | $1,243.41 | $2,347.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,821.61 / $2,821.61 / $2,821.61
| Facility | | $2,821.61 | $2,821.61 | $2,821.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.07 / $1,425.16 / $3,110.36
| Professional | | $1,401.07 | $1,425.16 | $3,110.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,823.10 / $1,823.10 / $2,077.19
| Facility | | $1,823.10 | $1,823.10 | $2,077.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.86 / $1,823.10 / $1,877.79
| Professional | | $1,330.86 | $1,823.10 | $1,877.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,569.06 / $2,257.29 / $3,668.09
| Professional | | $1,569.06 | $2,257.29 | $3,668.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.02 / $1,407.67 / $1,885.32
| Professional | | $1,076.02 | $1,407.67 | $1,885.32 |