- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,757.15 / $1,757.15 / $4,518.38
| Facility | | $1,757.15 | $1,757.15 | $4,518.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.15 / $2,359.60 / $2,359.60
| Professional | | $1,757.15 | $2,359.60 | $2,359.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,778.50 / $5,058.07 / $5,647.97
| Professional | | $3,778.50 | $5,058.07 | $5,647.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,619.00 / $2,619.00 / $3,273.75
| Professional | | $2,619.00 | $2,619.00 | $3,273.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,506.13 / $1,907.76 / $4,518.38
| Facility | | $1,506.13 | $1,907.76 | $4,518.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,280.21 / $3,012.25 / $5,020.42
| Professional | | $1,280.21 | $3,012.25 | $5,020.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $2,560.41 / $3,639.80
| Professional | | $1,054.29 | $2,560.41 | $3,639.80 |