- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,330.14 / $1,330.14 / $3,420.36
| Facility | | $1,330.14 | $1,330.14 | $3,420.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.14 / $1,786.19 / $1,786.19
| Professional | | $1,330.14 | $1,786.19 | $1,786.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,860.28 / $3,828.90 / $4,275.45
| Professional | | $2,860.28 | $3,828.90 | $4,275.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,183.53 / $2,183.53 / $3,205.52
| Professional | | $2,183.53 | $2,183.53 | $3,205.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,140.11 / $1,444.15 / $3,420.36
| Facility | | $1,140.11 | $1,444.15 | $3,420.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.10 / $2,280.23 / $3,800.40
| Professional | | $969.10 | $2,280.23 | $3,800.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.08 / $1,938.20 / $3,230.34
| Professional | | $798.08 | $1,938.20 | $3,230.34 |