- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $11,481.54 / $11,481.54
| Facility | | $1,412.54 | $11,481.54 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,445.44 / $1,548.82
| Professional | | $1,318.26 | $1,445.44 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,513.56 / $1,659.59
| Professional | | $1,380.38 | $1,513.56 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,235.94 / $7,244.36
| Facility | | $3,090.30 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $3,890.45
| Professional | | $2,187.76 | $2,187.76 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $851.14 / $2,344.23
| Professional | | $794.33 | $851.14 | $2,344.23 |