- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,219.13 / $2,219.13 / $4,715.64
| Facility | | $2,219.13 | $2,219.13 | $4,715.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,797.50 / $1,797.50 / $1,797.50
| Professional | | $1,797.50 | $1,797.50 | $1,797.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.47 / $1,549.20 / $1,704.12
| Professional | | $1,331.47 | $1,549.20 | $1,704.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $2,549.86 / $3,187.33
| Professional | | $2,549.86 | $2,549.86 | $3,187.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,219.13 / $2,219.13 / $2,687.37
| Professional | | $2,219.13 | $2,219.13 | $2,687.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,219.13 / $2,219.13 / $3,594.99
| Facility | | $2,219.13 | $2,219.13 | $3,594.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,797.50 / $1,797.50 / $2,219.13
| Professional | | $1,797.50 | $1,797.50 | $2,219.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.48 / $1,331.48 / $3,217.74
| Professional | | $1,331.48 | $1,331.48 | $3,217.74 |