- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,164.45 / $1,164.45 / $1,226.55
| Facility | | $1,164.45 | $1,164.45 | $1,226.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.78 / $1,214.73 / $1,448.01
| Professional | | $816.78 | $1,214.73 | $1,448.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,354.82 / $1,662.11 / $1,869.88
| Professional | | $1,354.82 | $1,662.11 | $1,869.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.47 / $1,122.47 / $1,122.47
| Facility | | $1,122.47 | $1,122.47 | $1,122.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.57 / $954.10 / $1,459.20
| Professional | | $341.57 | $954.10 | $1,459.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,204.55 / $9,804.04 / $10,161.49
| Facility | | $2,204.55 | $9,804.04 | $10,161.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.19 / $792.28 / $1,350.27
| Professional | | $528.19 | $792.28 | $1,350.27 |