- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,542.27 / $1,542.27 / $1,542.27
| Facility | | $1,542.27 | $1,542.27 | $1,542.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.30 / $1,542.27 / $2,284.65
| Professional | | $1,010.30 | $1,542.27 | $2,284.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,084.54 / $3,465.79 / $6,292.46
| Facility | | $3,084.54 | $3,465.79 | $6,292.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,481.65 / $1,481.65 / $1,600.18
| Professional | | $1,481.65 | $1,481.65 | $1,600.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,769.38 / $1,769.38 / $1,769.38
| Facility | | $1,769.38 | $1,769.38 | $1,769.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.65 / $1,291.65 / $3,084.82
| Professional | | $1,291.65 | $1,291.65 | $3,084.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $781.11 / $1,542.27 / $3,855.68
| Facility | | $781.11 | $1,542.27 | $3,855.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.11 / $781.11 / $781.11
| Professional | | $781.11 | $781.11 | $781.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,251.71 / $3,855.68 / $6,107.39
| Professional | | $2,251.71 | $3,855.68 | $6,107.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.68 / $1,209.93 / $1,864.47
| Professional | | $1,118.68 | $1,209.93 | $1,864.47 |