- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,322.35 / $1,322.35 / $1,396.83
| Facility | | $1,322.35 | $1,322.35 | $1,396.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.08 / $1,247.74 / $1,569.07
| Professional | | $1,063.08 | $1,247.74 | $1,569.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.80 / $3,194.39 / $3,194.39
| Facility | | $2,126.80 | $3,194.39 | $3,194.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.60 / $1,501.21 / $1,565.74
| Professional | | $1,303.60 | $1,501.21 | $1,565.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,516.14 / $1,516.14 / $2,065.07
| Facility | | $1,516.14 | $1,516.14 | $2,065.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.88 / $1,743.98 / $2,463.75
| Professional | | $169.88 | $1,743.98 | $2,463.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.25 / $1,057.80 / $1,686.61
| Professional | | $806.25 | $1,057.80 | $1,686.61 |