- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,882.66 / $3,765.31 / $7,530.63
| Facility | | $1,882.66 | $3,765.31 | $7,530.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,882.66 / $3,012.25 / $3,012.25
| Professional | | $1,882.66 | $3,012.25 | $3,012.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,631.64 / $1,631.64 / $1,631.64
| Facility | | $1,631.64 | $1,631.64 | $1,631.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.78 / $3,890.83 / $4,091.64
| Professional | | $3,388.78 | $3,890.83 | $4,091.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,631.64 / $2,510.21 / $3,162.86
| Facility | | $1,631.64 | $2,510.21 | $3,162.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,648.27 / $3,037.35 / $3,489.19
| Professional | | $2,648.27 | $3,037.35 | $3,489.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,171.43 / $1,506.13
| Professional | | $1,054.29 | $1,171.43 | $1,506.13 |