- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $2,290.87
| Facility | | $1,202.26 | $1,202.26 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $2,041.74
| Professional | | $1,202.26 | $1,445.44 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,548.82
| Facility | | $1,288.25 | $1,288.25 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Professional | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,290.87
| Facility | | $2,089.30 | $2,089.30 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,737.80 / $6,025.60
| Professional | | $1,023.29 | $1,737.80 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $16,595.87
| Facility | | $3,548.13 | $3,548.13 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,288.25 / $1,995.26
| Professional | | $933.25 | $1,288.25 | $1,995.26 |