- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $2,187.76
| Facility | | $1,584.89 | $1,584.89 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,071.52 / $1,584.89
| Professional | | $831.76 | $1,071.52 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,698.24
| Professional | | $1,288.25 | $1,288.25 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $2,344.23
| Facility | | $812.83 | $1,000.00 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,258.93
| Facility | | $1,148.15 | $1,148.15 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $758.58 / $1,258.93
| Professional | | $524.81 | $758.58 | $1,258.93 |