- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,323.16 / $1,323.16 / $1,526.73
| Facility | | $1,323.16 | $1,323.16 | $1,526.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.33 / $1,323.16 / $1,655.27
| Professional | | $1,204.33 | $1,323.16 | $1,655.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,874.60 / $3,874.60 / $3,874.60
| Facility | | $3,874.60 | $3,874.60 | $3,874.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.05 / $1,718.05 / $3,874.60
| Professional | | $1,718.05 | $1,718.05 | $3,874.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,815.81 / $1,815.81 / $2,852.38
| Facility | | $1,815.81 | $1,815.81 | $2,852.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.54 / $1,815.81 / $2,560.71
| Professional | | $1,325.54 | $1,815.81 | $2,560.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,154.62 / $3,099.68 / $5,036.97
| Professional | | $2,154.62 | $3,099.68 | $5,036.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,135.14 / $1,449.74 / $2,416.23
| Professional | | $1,135.14 | $1,449.74 | $2,416.23 |