- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,202.26 / $2,290.87
| Facility | | $891.25 | $1,202.26 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $2,137.96
| Professional | | $891.25 | $1,230.27 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,258.93 / $5,011.87
| Facility | | $933.25 | $1,258.93 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,258.93 / $2,754.23
| Professional | | $1,230.27 | $1,258.93 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $9,549.93
| Facility | | $1,621.81 | $1,621.81 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $3,630.78
| Professional | | $1,202.26 | $1,202.26 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,548.82 / $2,818.38
| Facility | | $1,348.96 | $1,548.82 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,148.15 / $1,737.80
| Professional | | $851.14 | $1,148.15 | $1,737.80 |