- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,360.25 / $1,360.25 / $3,497.78
| Facility | | $1,360.25 | $1,360.25 | $3,497.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.25 / $1,360.25 / $1,826.62
| Professional | | $1,360.25 | $1,360.25 | $1,826.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,925.02 / $3,915.57 / $4,372.22
| Professional | | $2,925.02 | $3,915.57 | $4,372.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,232.67 / $2,232.67 / $3,277.67
| Professional | | $2,232.67 | $2,232.67 | $3,277.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,165.93 / $1,476.84 / $3,497.78
| Facility | | $1,165.93 | $1,476.84 | $3,497.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.04 / $2,331.85 / $3,886.42
| Professional | | $991.04 | $2,331.85 | $3,886.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.15 / $2,040.37 / $2,988.66
| Professional | | $816.15 | $2,040.37 | $2,988.66 |