- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,297.08 / $2,246.86 / $2,907.19
| Facility | | $1,297.08 | $2,246.86 | $2,907.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.64 / $1,013.76 / $1,097.28
| Professional | | $872.64 | $1,013.76 | $1,097.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,152.00 / $2,119.67 / $3,019.16
| Facility | | $1,152.00 | $2,119.67 | $3,019.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.00 / $864.00 / $921.60
| Professional | | $864.00 | $864.00 | $921.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $960.00 / $2,400.00
| Facility | | $960.00 | $960.00 | $2,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,160.00 / $3,160.00 / $3,160.00
| Professional | | $3,160.00 | $3,160.00 | $3,160.00 |