- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.30 / $1,450.30 / $1,450.30
| Facility | | $1,450.30 | $1,450.30 | $1,450.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.70 / $1,979.77 / $6,582.10
| Professional | | $1,357.70 | $1,979.77 | $6,582.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.16 / $1,747.16 / $1,747.16
| Facility | | $1,747.16 | $1,747.16 | $1,747.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.43 / $1,747.16 / $1,747.16
| Professional | | $1,275.43 | $1,747.16 | $1,747.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,103.21 / $2,629.02 / $3,943.53
| Professional | | $2,103.21 | $2,629.02 | $3,943.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $728.07 / $728.07 / $1,975.73
| Facility | | $728.07 | $728.07 | $1,975.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.43 / $1,747.16 / $2,923.68
| Professional | | $1,275.43 | $1,747.16 | $2,923.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.72 / $1,127.77 / $1,699.21
| Professional | | $1,042.72 | $1,127.77 | $1,699.21 |