- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,526.52 / $1,526.52 / $2,249.88
| Facility | | $1,526.52 | $1,526.52 | $2,249.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.98 / $1,526.52 / $1,938.98
| Professional | | $1,469.98 | $1,526.52 | $1,938.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,017.28 / $2,017.28 / $2,017.28
| Facility | | $2,017.28 | $2,017.28 | $2,017.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.61 / $2,017.28 / $2,017.28
| Professional | | $1,472.61 | $2,017.28 | $2,017.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,039.78 / $2,001.40 / $17,217.72
| Facility | | $1,039.78 | $2,001.40 | $17,217.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.74 / $1,610.60 / $3,193.01
| Professional | | $1,073.74 | $1,610.60 | $3,193.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.74 / $1,543.37 / $2,310.62
| Professional | | $1,073.74 | $1,543.37 | $2,310.62 |