- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,070.78 / $2,070.78 / $2,505.83
| Facility | | $2,070.78 | $2,070.78 | $2,505.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.60 / $1,557.88 / $2,505.83
| Professional | | $1,234.60 | $1,557.88 | $2,505.83 |
- 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
- $1,276.04 / $1,922.80 / $2,240.94
| Professional | | $1,276.04 | $1,922.80 | $2,240.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.96 / $1,953.40 / $5,405.12
| Professional | | $1,303.96 | $1,953.40 | $5,405.12 |
- 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
- $1,289.75 / $1,614.46 / $2,857.59
| Professional | | $1,289.75 | $1,614.46 | $2,857.59 |