- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,832.74 / $1,832.74 / $2,363.11
| Facility | | $1,832.74 | $1,832.74 | $2,363.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.10 / $1,843.07 / $2,848.01
| Professional | | $1,528.10 | $1,843.07 | $2,848.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,422.37 / $4,030.05 / $6,739.33
| Facility | | $3,422.37 | $4,030.05 | $6,739.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,974.14 / $2,055.03 / $3,099.63
| Professional | | $1,974.14 | $2,055.03 | $3,099.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,400.00 / $2,400.00 / $2,400.00
| Facility | | $2,400.00 | $2,400.00 | $2,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.00 / $2,400.00 / $2,814.37
| Professional | | $1,752.00 | $2,400.00 | $2,814.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,366.51 / $1,763.61 / $2,600.71
| Professional | | $1,366.51 | $1,763.61 | $2,600.71 |