- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,294.26 / $1,342.79 / $3,543.03
| Facility | | $1,294.26 | $1,342.79 | $3,543.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.26 / $1,342.79 / $1,375.15
| Professional | | $1,294.26 | $1,342.79 | $1,375.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Facility | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Professional | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.71 / $573.71 / $573.71
| Professional | | $573.71 | $573.71 | $573.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.63 / $1,388.63 / $1,617.82
| Professional | | $1,388.63 | $1,388.63 | $1,617.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Professional | | $1,429.07 | $1,429.07 | $1,429.07 |