- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,630.27 / $2,630.27
| Facility | | $1,445.44 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,318.26 / $1,479.11
| Professional | | $812.83 | $1,318.26 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Professional | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,818.38 / $5,248.07
| Facility | | $1,445.44 | $2,818.38 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,317.64 / $8,317.64
| Professional | | $8,317.64 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $562.34 / $1,412.54
| Professional | | $467.74 | $562.34 | $1,412.54 |