- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.43 / $1,060.43 / $1,060.43
| Facility | | $1,060.43 | $1,060.43 | $1,060.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $862.48 / $1,074.56 / $1,322.54
| Professional | | $862.48 | $1,074.56 | $1,322.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,061.71 / $1,336.47 / $1,603.76
| Professional | | $1,061.71 | $1,336.47 | $1,603.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.44 / $1,042.44 / $1,042.44
| Facility | | $1,042.44 | $1,042.44 | $1,042.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.07 / $886.07 / $1,672.50
| Professional | | $886.07 | $886.07 | $1,672.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,554.45 / $7,614.56 / $7,892.17
| Facility | | $1,554.45 | $7,614.56 | $7,892.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.09 / $612.00 / $935.80
| Professional | | $428.09 | $612.00 | $935.80 |