- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,152.65 / $8,152.65 / $8,152.65
| Facility | | $8,152.65 | $8,152.65 | $8,152.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.43 / $1,000.75 / $4,982.54
| Professional | | $983.43 | $1,000.75 | $4,982.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,480.65 / $1,480.65 / $1,480.65
| Facility | | $1,480.65 | $1,480.65 | $1,480.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.57 / $1,480.65 / $1,583.04
| Professional | | $1,128.57 | $1,480.65 | $1,583.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $732.18 / $1,784.90 / $1,857.02
| Facility | | $732.18 | $1,784.90 | $1,857.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.51 / $1,340.40 / $1,933.40
| Professional | | $893.51 | $1,340.40 | $1,933.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.46 / $1,645.06 / $2,572.41
| Professional | | $1,400.46 | $1,645.06 | $2,572.41 |