- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $935.26 / $1,042.15 / $6,336.27
| Facility | | $935.26 | $1,042.15 | $6,336.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.15 / $1,042.15 / $1,068.86
| Professional | | $1,042.15 | $1,042.15 | $1,068.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.09 / $1,402.89 / $1,843.80
| Professional | | $1,336.09 | $1,402.89 | $1,843.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,428.21 / $3,291.46 / $7,618.13
| Facility | | $2,428.21 | $3,291.46 | $7,618.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.15 / $1,336.09 / $1,688.28
| Facility | | $1,042.15 | $1,336.09 | $1,688.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.48 / $1,202.48 / $1,603.31
| Facility | | $1,202.48 | $1,202.48 | $1,603.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.16 / $734.85 / $1,216.66
| Professional | | $561.16 | $734.85 | $1,216.66 |