- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,888.44 / $5,888.44
| Facility | | $3,715.35 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $912.01 / $1,071.52
| Professional | | $851.14 | $912.01 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,513.56 / $1,621.81
| Facility | | $1,348.96 | $1,513.56 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,862.09
| Professional | | $1,513.56 | $1,513.56 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Facility | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $776.25 / $1,862.09
| Professional | | $549.54 | $776.25 | $1,862.09 |