- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,625.33 / $1,625.33 / $1,625.33
| Facility | | $1,625.33 | $1,625.33 | $1,625.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,763.06 / $7,001.33 / $7,001.33
| Professional | | $2,763.06 | $7,001.33 | $7,001.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,711.70 / $2,013.77 / $2,013.77
| Professional | | $1,711.70 | $2,013.77 | $2,013.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,205.33 / $1,873.14 / $6,407.00
| Facility | | $1,205.33 | $1,873.14 | $6,407.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.28 / $1,682.07 / $10,836.20
| Professional | | $1,400.28 | $1,682.07 | $10,836.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.28 / $1,634.28 / $2,273.15
| Professional | | $1,400.28 | $1,634.28 | $2,273.15 |