- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,290.07 / $2,617.54 / $3,926.31
| Facility | | $1,290.07 | $2,617.54 | $3,926.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.62 / $933.53 / $1,105.78
| Professional | | $741.62 | $933.53 | $1,105.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,156.08 / $1,156.08 / $1,156.08
| Facility | | $1,156.08 | $1,156.08 | $1,156.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.08 / $1,331.58 / $1,736.35
| Professional | | $1,156.08 | $1,331.58 | $1,736.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $889.27 / $1,156.08 / $1,773.25
| Facility | | $889.27 | $1,156.08 | $1,773.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.77 / $1,308.77 / $5,826.31
| Professional | | $1,308.77 | $1,308.77 | $5,826.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.77 / $1,308.77 / $1,308.77
| Professional | | $1,308.77 | $1,308.77 | $1,308.77 |