- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,010.82 / $1,263.53 / $3,032.47
| Facility | | $1,010.82 | $1,263.53 | $3,032.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $947.65 / $947.65 / $1,351.98
| Professional | | $947.65 | $947.65 | $1,351.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $821.29 / $821.29 / $1,108.74
| Facility | | $821.29 | $821.29 | $1,108.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.80 / $1,538.80 / $1,843.65
| Professional | | $1,538.80 | $1,538.80 | $1,843.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $947.65 / $1,263.53 / $2,122.73
| Facility | | $947.65 | $1,263.53 | $2,122.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.67 / $530.67 / $1,667.86
| Professional | | $530.67 | $530.67 | $1,667.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.67 / $530.67 / $1,263.53
| Professional | | $530.67 | $530.67 | $1,263.53 |