- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,808.12 / $2,808.12 / $3,366.89
| Facility | | $2,808.12 | $2,808.12 | $3,366.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.09 / $2,187.15 / $3,366.89
| Professional | | $1,690.09 | $2,187.15 | $3,366.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $404.28 / $489.41 / $658.42
| Facility | | $404.28 | $489.41 | $658.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,735.94 / $2,615.80 / $3,048.60
| Professional | | $1,735.94 | $2,615.80 | $3,048.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,767.89 / $2,659.23 / $7,297.44
| Professional | | $1,767.89 | $2,659.23 | $7,297.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,485.00 / $4,121.00 / $7,227.00
| Facility | | $1,485.00 | $4,121.00 | $7,227.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,617.57 / $2,241.50 / $3,841.61
| Professional | | $1,617.57 | $2,241.50 | $3,841.61 |