- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,023.29 / $2,238.72
| Facility | | $831.76 | $1,023.29 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,071.52 / $1,737.80
| Professional | | $831.76 | $1,071.52 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,202.26 / $4,265.80
| Facility | | $891.25 | $1,202.26 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,202.26 / $2,344.23
| Professional | | $1,047.13 | $1,202.26 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $7,244.36
| Facility | | $1,230.27 | $1,230.27 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $2,818.38
| Professional | | $891.25 | $891.25 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,445.44 / $2,630.27
| Facility | | $1,071.52 | $1,445.44 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $977.24 / $1,621.81
| Professional | | $758.58 | $977.24 | $1,621.81 |