- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,405.80 / $1,405.80 / $1,480.78
| Facility | | $1,405.80 | $1,405.80 | $1,480.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.38 / $1,480.78 / $1,775.46
| Professional | | $1,143.38 | $1,480.78 | $1,775.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,855.67 / $2,144.86 / $2,474.21
| Professional | | $1,855.67 | $2,144.86 | $2,474.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,293.24 / $1,293.24 / $1,293.24
| Facility | | $1,293.24 | $1,293.24 | $1,293.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.30 / $1,491.30 / $2,310.00
| Professional | | $1,491.30 | $1,491.30 | $2,310.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,985.99 / $9,600.49 / $9,950.49
| Facility | | $2,985.99 | $9,600.49 | $9,950.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.36 / $930.08 / $1,570.80
| Facility | | $117.36 | $930.08 | $1,570.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.32 / $1,002.92 / $1,768.81
| Professional | | $662.32 | $1,002.92 | $1,768.81 |