- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.44 / $3,237.42 / $6,999.84
| Facility | | $2,187.44 | $3,237.42 | $6,999.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,916.60 / $2,916.60 / $6,999.84
| Professional | | $2,916.60 | $2,916.60 | $6,999.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,895.79 / $1,895.79 / $7,791.70
| Facility | | $1,895.79 | $1,895.79 | $7,791.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,552.58 / $3,552.58 / $4,256.39
| Professional | | $3,552.58 | $3,552.58 | $4,256.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,158.28 / $2,916.60 / $4,899.89
| Facility | | $2,158.28 | $2,916.60 | $4,899.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.97 / $1,224.97 / $4,374.89
| Professional | | $1,224.97 | $1,224.97 | $4,374.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.97 / $1,224.97 / $1,866.62
| Professional | | $1,224.97 | $1,224.97 | $1,866.62 |