- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,686.54 / $1,686.54 / $2,468.11
| Facility | | $1,686.54 | $1,686.54 | $2,468.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,686.54 / $2,468.11 / $2,776.63
| Professional | | $1,686.54 | $2,468.11 | $2,776.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.33 / $1,301.33 / $1,301.33
| Professional | | $1,301.33 | $1,301.33 | $1,301.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $6,466.79
| Facility | | $1,748.25 | $1,748.25 | $6,466.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,748.25
| Professional | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $722.10 / $802.34 / $1,756.82
| Professional | | $722.10 | $802.34 | $1,756.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.41 / $1,713.97 / $2,228.16
| Professional | | $1,645.41 | $1,713.97 | $2,228.16 |