- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,469.98 / $1,469.98 / $1,696.14
| Facility | | $1,469.98 | $1,469.98 | $1,696.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,321.32 / $1,469.98 / $1,721.81
| Professional | | $1,321.32 | $1,469.98 | $1,721.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,304.52 / $4,304.52 / $4,304.52
| Facility | | $4,304.52 | $4,304.52 | $4,304.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,890.51 / $1,966.25 / $4,304.52
| Professional | | $1,890.51 | $1,966.25 | $4,304.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,017.28 / $2,017.28 / $3,168.89
| Facility | | $2,017.28 | $2,017.28 | $3,168.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.61 / $2,017.28 / $2,844.87
| Professional | | $1,472.61 | $2,017.28 | $2,844.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,393.69 / $3,443.62 / $5,595.88
| Professional | | $2,393.69 | $3,443.62 | $5,595.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,261.08 / $1,610.60 / $2,684.34
| Professional | | $1,261.08 | $1,610.60 | $2,684.34 |