- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,383.06 / $1,383.06 / $1,680.08
| Facility | | $1,383.06 | $1,383.06 | $1,680.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,280.69 / $1,539.13 / $1,680.08
| Professional | | $1,280.69 | $1,539.13 | $1,680.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,926.02 / $3,307.67 / $4,077.76
| Professional | | $2,926.02 | $3,307.67 | $4,077.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,897.55 / $3,265.42 / $5,029.74
| Professional | | $1,897.55 | $3,265.42 | $5,029.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,383.06 / $2,190.82 / $2,732.71
| Facility | | $1,383.06 | $2,190.82 | $2,732.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.06 / $3,336.64 / $9,617.84
| Professional | | $1,732.06 | $3,336.64 | $9,617.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,719.67 / $3,082.11 / $3,715.26
| Professional | | $1,719.67 | $3,082.11 | $3,715.26 |