- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,320.91 / $1,455.83 / $1,546.74
| Facility | | $1,320.91 | $1,455.83 | $1,546.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,069.71 / $1,386.11 / $1,780.48
| Professional | | $1,069.71 | $1,386.11 | $1,780.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,120.40 / $1,120.40 / $2,162.37
| Facility | | $1,120.40 | $1,120.40 | $2,162.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.40 / $1,185.05 / $1,633.44
| Professional | | $1,120.40 | $1,185.05 | $1,633.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.19 / $144.19 / $211.75
| Facility | | $144.19 | $144.19 | $211.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.56 / $144.19 / $2,627.26
| Professional | | $122.56 | $144.19 | $2,627.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.23 / $863.16 / $1,525.70
| Professional | | $690.23 | $863.16 | $1,525.70 |