- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,548.82 / $2,630.27
| Professional | | $1,202.26 | $1,548.82 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $3,801.89
| Facility | | $1,819.70 | $1,819.70 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $3,311.31
| Professional | | $1,949.84 | $1,949.84 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,011.87 / $5,011.87
| Facility | | $2,137.96 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $14,791.08
| Professional | | $1,548.82 | $1,548.82 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $3,235.94
| Facility | | $1,819.70 | $1,819.70 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,778.28 / $2,344.23
| Professional | | $1,348.96 | $1,778.28 | $2,344.23 |