- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,629.28 / $1,629.28 / $1,629.28
| Facility | | $1,629.28 | $1,629.28 | $1,629.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.30 / $1,629.28 / $2,985.92
| Professional | | $1,392.30 | $1,629.28 | $2,985.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,258.55 / $3,661.31 / $6,647.44
| Facility | | $3,258.55 | $3,661.31 | $6,647.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.88 / $1,947.88 / $2,103.71
| Professional | | $1,947.88 | $1,947.88 | $2,103.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,561.34 / $2,561.34 / $2,561.34
| Facility | | $2,561.34 | $2,561.34 | $2,561.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.78 / $1,869.78 / $4,063.71
| Professional | | $1,869.78 | $1,869.78 | $4,063.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,038.06 / $1,710.74 / $4,073.19
| Facility | | $1,038.06 | $1,710.74 | $4,073.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,038.06 / $1,038.06 / $1,038.06
| Professional | | $1,038.06 | $1,038.06 | $1,038.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,378.73 / $4,073.19 / $6,517.10
| Professional | | $2,378.73 | $4,073.19 | $6,517.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.68 / $1,607.95 / $2,477.80
| Professional | | $1,486.68 | $1,607.95 | $2,477.80 |