- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,077.96 / $1,110.14 / $1,791.67
| Facility | | $1,077.96 | $1,110.14 | $1,791.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.54 / $787.48 / $1,110.14
| Professional | | $764.54 | $787.48 | $1,110.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.23 / $1,152.46 / $2,035.44
| Professional | | $1,126.23 | $1,152.46 | $2,035.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.47 / $1,122.47 / $1,459.20
| Facility | | $1,122.47 | $1,122.47 | $1,459.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.82 / $1,122.47 / $2,077.50
| Professional | | $140.82 | $1,122.47 | $2,077.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.17 / $179.17 / $179.17
| Professional | | $179.17 | $179.17 | $179.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.13 / $883.25 / $1,472.09
| Professional | | $607.13 | $883.25 | $1,472.09 |