- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,025.60 / $6,025.60
| Facility | | $3,801.89 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $933.25 / $1,096.48
| Professional | | $870.96 | $933.25 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,548.82 / $1,659.59
| Facility | | $1,380.38 | $1,548.82 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Professional | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $794.33 / $1,905.46
| Professional | | $562.34 | $794.33 | $1,905.46 |