- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,919.15 / $1,919.15 / $2,438.87
| Facility | | $1,919.15 | $1,919.15 | $2,438.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.11 / $1,571.31 / $2,438.87
| Professional | | $1,146.11 | $1,571.31 | $2,438.87 |
- 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
- $1,148.29 / $1,730.30 / $2,062.50
| Professional | | $1,148.29 | $1,730.30 | $2,062.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,209.38 / $1,883.98 / $5,016.12
| Professional | | $1,209.38 | $1,883.98 | $5,016.12 |
- 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
- $1,252.40 / $1,586.38 / $2,796.69
| Professional | | $1,252.40 | $1,586.38 | $2,796.69 |