- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.26 / $1,304.26 / $3,353.80
| Facility | | $1,304.26 | $1,304.26 | $3,353.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.26 / $1,751.43 / $1,751.43
| Professional | | $1,304.26 | $1,751.43 | $1,751.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,804.61 / $3,754.39 / $4,192.25
| Professional | | $2,804.61 | $3,754.39 | $4,192.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,140.98 / $2,140.98 / $3,143.07
| Professional | | $2,140.98 | $2,140.98 | $3,143.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,117.93 / $1,416.05 / $3,353.80
| Facility | | $1,117.93 | $1,416.05 | $3,353.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.24 / $2,235.86 / $3,726.44
| Professional | | $950.24 | $2,235.86 | $3,726.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $1,900.48 / $3,167.47
| Professional | | $782.55 | $1,900.48 | $3,167.47 |