- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $983.72 / $1,278.83 / $1,947.77
| Facility | | $983.72 | $1,278.83 | $1,947.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.72 / $983.72 / $983.72
| Professional | | $983.72 | $983.72 | $983.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,046.93 / $1,046.93 / $1,046.93
| Facility | | $1,046.93 | $1,046.93 | $1,046.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.93 / $1,046.93 / $1,046.93
| Professional | | $1,046.93 | $1,046.93 | $1,046.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,690.00 / $5,234.64 / $5,234.64
| Facility | | $1,690.00 | $5,234.64 | $5,234.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.42 / $1,185.20 / $1,185.20
| Professional | | $1,007.42 | $1,185.20 | $1,185.20 |