- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,149.10 / $2,149.10 / $2,660.20
| Facility | | $2,149.10 | $2,149.10 | $2,660.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.98 / $1,663.63 / $2,660.20
| Professional | | $1,251.98 | $1,663.63 | $2,660.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $403.29 / $489.41 / $658.42
| Facility | | $403.29 | $489.41 | $658.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.21 / $1,954.70 / $2,278.11
| Professional | | $1,297.21 | $1,954.70 | $2,278.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.24 / $2,070.30 / $5,408.73
| Professional | | $1,347.24 | $2,070.30 | $5,408.73 |
- 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
- $1,349.03 / $1,708.77 / $2,949.08
| Professional | | $1,349.03 | $1,708.77 | $2,949.08 |