- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,633.28 / $1,633.28 / $1,633.28
| Facility | | $1,633.28 | $1,633.28 | $1,633.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.40 / $1,655.05 / $1,958.45
| Professional | | $1,328.40 | $1,655.05 | $1,958.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.25 / $2,058.44 / $2,470.14
| Professional | | $1,635.25 | $2,058.44 | $2,470.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $1,450.41
| Facility | | $1,450.41 | $1,450.41 | $1,450.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.84 / $1,232.84 / $3,030.00
| Professional | | $1,232.84 | $1,232.84 | $3,030.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.75 / $11,728.00 / $12,155.63
| Facility | | $2,884.75 | $11,728.00 | $12,155.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $733.34 / $1,070.93 / $1,669.55
| Professional | | $733.34 | $1,070.93 | $1,669.55 |