- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,412.54
| Facility | | $1,096.48 | $1,096.48 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $870.96 / $2,344.23
| Professional | | $549.54 | $870.96 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $954.99
| Facility | | $954.99 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Professional | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $9,120.11
| Facility | | $2,454.71 | $2,454.71 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,089.30 / $3,388.44
| Professional | | $1,445.44 | $2,089.30 | $3,388.44 |