- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,409.51 / $1,409.51 / $1,409.51
| Facility | | $1,409.51 | $1,409.51 | $1,409.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.17 / $1,409.51 / $2,178.35
| Professional | | $1,222.17 | $1,409.51 | $2,178.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,819.01 / $3,167.44 / $5,750.78
| Facility | | $2,819.01 | $3,167.44 | $5,750.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,624.28 / $1,624.28 / $1,754.22
| Professional | | $1,624.28 | $1,624.28 | $1,754.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,373.71 / $2,373.71 / $2,373.71
| Facility | | $2,373.71 | $2,373.71 | $2,373.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.65 / $2,017.65 / $2,950.52
| Professional | | $2,017.65 | $2,017.65 | $2,950.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.27 / $1,489.16 / $3,523.76
| Facility | | $860.27 | $1,489.16 | $3,523.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.27 / $860.27 / $860.27
| Professional | | $860.27 | $860.27 | $860.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,057.88 / $3,608.33 / $5,638.02
| Professional | | $2,057.88 | $3,608.33 | $5,638.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.05 / $1,332.55 / $2,053.41
| Professional | | $1,232.05 | $1,332.55 | $2,053.41 |