- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,238.06 / $1,238.06 / $1,889.81
| Facility | | $1,238.06 | $1,238.06 | $1,889.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.79 / $1,238.06 / $1,483.95
| Professional | | $1,033.79 | $1,238.06 | $1,483.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,283.07 / $1,463.52 / $1,594.53
| Facility | | $1,283.07 | $1,463.52 | $1,594.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.07 / $1,417.36 / $1,417.36
| Professional | | $727.07 | $1,417.36 | $1,417.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.52 / $1,373.52 / $1,373.52
| Facility | | $1,373.52 | $1,373.52 | $1,373.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.42 / $1,624.50 / $3,361.70
| Professional | | $1,043.42 | $1,624.50 | $3,361.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.19 / $1,275.61 / $1,949.97
| Professional | | $879.19 | $1,275.61 | $1,949.97 |