- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,819.70 / $1,819.70
| Facility | | $1,412.54 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,819.70 / $3,019.95
| Professional | | $1,096.48 | $1,819.70 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Professional | | $6,309.57 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $9,120.11
| Facility | | $2,454.71 | $2,454.71 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $3,388.44
| Professional | | $1,548.82 | $2,187.76 | $3,388.44 |