- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $2,754.23
| Facility | | $1,258.93 | $1,258.93 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $933.25 / $1,230.27
| Professional | | $691.83 | $933.25 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,089.30 / $3,388.44
| Facility | | $1,584.89 | $2,089.30 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $234.42 / $1,258.93
| Professional | | $162.18 | $234.42 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $7,244.36
| Facility | | $812.83 | $812.83 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,344.23 / $2,754.23
| Professional | | $1,698.24 | $2,344.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $758.58 / $2,238.72
| Professional | | $602.56 | $758.58 | $2,238.72 |