- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $873.16 / $873.16 / $2,241.91
| Facility | | $873.16 | $873.16 | $2,241.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.16 / $1,212.79 / $2,241.91
| Professional | | $873.16 | $1,212.79 | $2,241.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,695.08 / $2,695.08 / $2,695.08
| Facility | | $2,695.08 | $2,695.08 | $2,695.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,481.54 / $1,487.71 / $3,288.95
| Professional | | $1,481.54 | $1,487.71 | $3,288.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.24 / $1,786.24 / $1,984.06
| Facility | | $1,786.24 | $1,786.24 | $1,984.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.96 / $1,747.86 / $1,839.83
| Professional | | $1,303.96 | $1,747.86 | $1,839.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.70 / $2,156.06 / $3,503.60
| Professional | | $1,498.70 | $2,156.06 | $3,503.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.56 / $1,230.61 / $1,883.18
| Professional | | $963.56 | $1,230.61 | $1,883.18 |