- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,057.33 / $1,500.21 / $3,608.96
| Facility | | $1,057.33 | $1,500.21 | $3,608.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.95 / $1,292.05 / $1,858.95
| Professional | | $816.95 | $1,292.05 | $1,858.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $961.22 / $1,371.55 / $2,841.70
| Facility | | $961.22 | $1,371.55 | $2,841.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $711.40 / $1,127.92 / $1,704.77
| Professional | | $711.40 | $1,127.92 | $1,704.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $410.75 / $555.12 / $1,052.39
| Facility | | $410.75 | $555.12 | $1,052.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $579.00 / $2,109.44 / $2,109.44
| Professional | | $579.00 | $2,109.44 | $2,109.44 |