- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,635.63 / $1,660.63 / $1,905.18
| Facility | | $1,635.63 | $1,660.63 | $1,905.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,421.96 / $1,635.63 / $2,365.81
| Professional | | $1,421.96 | $1,635.63 | $2,365.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,054.36 / $3,431.88 / $6,230.89
| Facility | | $3,054.36 | $3,431.88 | $6,230.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,738.10 / $1,738.10 / $2,565.12
| Professional | | $1,738.10 | $1,738.10 | $2,565.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,808.29 / $1,808.29 / $1,808.29
| Facility | | $1,808.29 | $1,808.29 | $1,808.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.05 / $1,537.05 / $3,759.00
| Professional | | $1,537.05 | $1,537.05 | $3,759.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,218.34 / $1,615.24 / $2,299.37
| Professional | | $1,218.34 | $1,615.24 | $2,299.37 |