- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,090.30 / $4,365.16
| Facility | | $1,230.27 | $3,090.30 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $1,348.96
| Professional | | $870.96 | $1,230.27 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,995.26 / $2,691.53
| Facility | | $1,659.59 | $1,995.26 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,778.28 / $3,630.78
| Professional | | $1,230.27 | $1,778.28 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,454.71 / $3,801.89
| Professional | | $1,479.11 | $2,454.71 | $3,801.89 |