- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,919.60 / $5,342.87 / $5,926.79
| Facility | | $2,919.60 | $5,342.87 | $5,926.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.48 / $3,357.54 / $5,926.79
| Professional | | $2,306.48 | $3,357.54 | $5,926.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.80 / $1,459.80 / $1,459.80
| Professional | | $1,459.80 | $1,459.80 | $1,459.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,600.84 / $3,600.84 / $3,600.84
| Facility | | $3,600.84 | $3,600.84 | $3,600.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,600.84 / $3,600.84 / $3,600.84
| Professional | | $3,600.84 | $3,600.84 | $3,600.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,897.74 / $1,992.63 / $2,448.08
| Facility | | $1,897.74 | $1,992.63 | $2,448.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,264.33 / $2,736.25 / $4,193.50
| Professional | | $1,264.33 | $2,736.25 | $4,193.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $4,379.39
| Professional | | $1,226.23 | $1,751.76 | $4,379.39 |