- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $2,570.40
| Facility | | $1,288.25 | $1,288.25 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,318.26 / $1,380.38
| Professional | | $977.24 | $1,318.26 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Professional | | $6,456.54 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $35,481.34
| Facility | | $4,466.84 | $4,466.84 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $2,344.23
| Professional | | $1,096.48 | $1,659.59 | $2,344.23 |