- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,239.33 / $1,380.98 / $8,396.36
| Facility | | $1,239.33 | $1,380.98 | $8,396.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.98 / $1,380.98 / $1,416.39
| Professional | | $1,380.98 | $1,380.98 | $1,416.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.48 / $1,770.48 / $2,421.13
| Professional | | $1,770.48 | $1,770.48 | $2,421.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,217.66 / $4,361.57 / $10,094.91
| Facility | | $3,217.66 | $4,361.57 | $10,094.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,239.33 / $1,770.48 / $2,195.40
| Facility | | $1,239.33 | $1,770.48 | $2,195.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,593.43 / $1,770.48 / $1,770.48
| Facility | | $1,593.43 | $1,770.48 | $1,770.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.60 / $1,009.85 / $1,612.22
| Professional | | $743.60 | $1,009.85 | $1,612.22 |