- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,139.30 / $1,519.06 / $3,645.74
| Facility | | $1,139.30 | $1,519.06 | $3,645.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.09 / $1,139.30 / $1,139.30
| Professional | | $1,124.09 | $1,139.30 | $1,139.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $987.39 / $987.39 / $4,058.17
| Facility | | $987.39 | $987.39 | $4,058.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,850.06 / $1,850.06 / $2,216.58
| Professional | | $1,850.06 | $1,850.06 | $2,216.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,124.09 / $1,519.06 / $2,552.02
| Facility | | $1,124.09 | $1,519.06 | $2,552.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.01 / $638.01 / $5,704.42
| Professional | | $638.01 | $638.01 | $5,704.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.01 / $638.01 / $972.20
| Professional | | $638.01 | $638.01 | $972.20 |