- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,104.68 / $1,104.68 / $1,104.68
| Facility | | $1,104.68 | $1,104.68 | $1,104.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.47 / $1,104.68 / $1,377.72
| Professional | | $898.47 | $1,104.68 | $1,377.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.97 / $1,392.23 / $1,670.67
| Professional | | $1,105.97 | $1,392.23 | $1,670.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.30 / $1,232.30 / $2,051.25
| Professional | | $1,232.30 | $1,232.30 | $2,051.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,618.92 / $7,933.12 / $8,222.39
| Facility | | $1,618.92 | $7,933.12 | $8,222.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $445.85 / $640.66 / $990.64
| Professional | | $445.85 | $640.66 | $990.64 |