- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,112.45 / $1,368.31 / $2,714.38
| Facility | | $1,112.45 | $1,368.31 | $2,714.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.41 / $1,047.02 / $1,112.45
| Professional | | $826.41 | $1,047.02 | $1,112.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $982.67 / $1,156.08 / $1,906.82
| Facility | | $982.67 | $1,156.08 | $1,906.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.20 / $1,156.08 / $2,329.63
| Professional | | $1,042.20 | $1,156.08 | $2,329.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.45 / $1,112.45 / $1,112.45
| Professional | | $1,112.45 | $1,112.45 | $1,112.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.45 / $1,112.45 / $1,112.45
| Professional | | $1,112.45 | $1,112.45 | $1,112.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.77 / $1,308.77 / $1,388.34
| Professional | | $1,308.77 | $1,308.77 | $1,388.34 |