- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,657.22 / $1,657.22 / $2,133.34
| Facility | | $1,657.22 | $1,657.22 | $2,133.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.53 / $1,368.50 / $2,133.34
| Professional | | $950.53 | $1,368.50 | $2,133.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $403.29 / $489.41 / $658.42
| Facility | | $403.29 | $489.41 | $658.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.51 / $1,525.70 / $1,827.10
| Professional | | $1,012.51 | $1,525.70 | $1,827.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.76 / $1,628.04 / $4,324.06
| Professional | | $1,044.76 | $1,628.04 | $4,324.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,308.80 / $4,121.00 / $6,325.00
| Facility | | $1,308.80 | $4,121.00 | $6,325.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.06 / $1,385.80 / $2,412.92
| Professional | | $1,094.06 | $1,385.80 | $2,412.92 |