- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,757.15 / $1,757.15 / $4,518.38
| Facility | | $1,757.15 | $1,757.15 | $4,518.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.15 / $2,359.60 / $2,359.60
| Professional | | $1,757.15 | $2,359.60 | $2,359.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,778.50 / $5,058.07 / $5,647.97
| Professional | | $3,778.50 | $5,058.07 | $5,647.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.39 / $2,884.39 / $4,234.42
| Professional | | $2,884.39 | $2,884.39 | $4,234.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,506.13 / $1,957.96 / $4,518.38
| Facility | | $1,506.13 | $1,957.96 | $4,518.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.13 / $3,639.80 / $5,020.42
| Professional | | $1,506.13 | $3,639.80 | $5,020.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $2,560.41 / $4,267.35
| Professional | | $1,054.29 | $2,560.41 | $4,267.35 |