- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,383.32 / $7,248.60 / $9,503.41
| Facility | | $1,383.32 | $7,248.60 | $9,503.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.32 / $1,383.32 / $1,383.32
| Professional | | $1,383.32 | $1,383.32 | $1,383.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,313.76 / $1,351.21 / $4,235.02
| Facility | | $1,313.76 | $1,351.21 | $4,235.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.42 / $1,844.42 / $1,844.42
| Professional | | $1,844.42 | $1,844.42 | $1,844.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,537.02 / $1,767.57 / $1,844.42
| Facility | | $1,537.02 | $1,767.57 | $1,844.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.02 / $1,768.31 / $2,296.96
| Professional | | $1,537.02 | $1,768.31 | $2,296.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.54 / $645.54 / $922.21
| Professional | | $645.54 | $645.54 | $922.21 |