- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.36 / $1,285.36 / $1,483.11
| Facility | | $1,285.36 | $1,285.36 | $1,483.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.36 / $1,483.11 / $1,982.08
| Professional | | $1,285.36 | $1,483.11 | $1,982.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,763.92 / $3,763.92 / $3,763.92
| Facility | | $3,763.92 | $3,763.92 | $3,763.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.33 / $2,048.37 / $4,593.30
| Professional | | $2,017.33 | $2,048.37 | $4,593.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.75 / $2,326.75 / $2,770.88
| Facility | | $2,326.75 | $2,326.75 | $2,770.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.53 / $2,326.75 / $2,480.44
| Professional | | $1,698.53 | $2,326.75 | $2,480.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,093.06 / $3,011.14 / $4,893.10
| Professional | | $2,093.06 | $3,011.14 | $4,893.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.70 / $1,718.66 / $2,514.92
| Professional | | $1,345.70 | $1,718.66 | $2,514.92 |