- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,109.68 / $1,202.80 / $1,804.20
| Facility | | $1,109.68 | $1,202.80 | $1,804.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.69 / $1,202.80 / $1,701.39
| Professional | | $985.69 | $1,202.80 | $1,701.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.27 / $1,926.10 / $1,926.10
| Professional | | $1,455.27 | $1,926.10 | $1,926.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,327.44 / $1,766.69 / $2,187.77
| Professional | | $1,327.44 | $1,766.69 | $2,187.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,104.00 / $4,555.00 / $8,929.00
| Facility | | $2,104.00 | $4,555.00 | $8,929.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $778.08 / $1,086.92 / $1,966.74
| Professional | | $778.08 | $1,086.92 | $1,966.74 |