- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.51 / $1,122.51 / $1,708.69
| Facility | | $1,122.51 | $1,122.51 | $1,708.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.86 / $1,122.51 / $1,348.52
| Professional | | $936.86 | $1,122.51 | $1,348.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,163.45 / $1,323.25 / $1,441.71
| Facility | | $1,163.45 | $1,323.25 | $1,441.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.38 / $1,281.52 / $1,281.52
| Professional | | $657.38 | $1,281.52 | $1,281.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,246.15 / $1,246.15 / $1,246.15
| Facility | | $1,246.15 | $1,246.15 | $1,246.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.79 / $1,487.24 / $3,065.37
| Professional | | $940.79 | $1,487.24 | $3,065.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.08 / $1,181.21 / $1,806.11
| Professional | | $853.08 | $1,181.21 | $1,806.11 |