- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,453.51 / $1,453.51 / $11,860.60
| Facility | | $1,453.51 | $1,453.51 | $11,860.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.51 / $1,453.51 / $1,511.65
| Professional | | $1,453.51 | $1,453.51 | $1,511.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.41 / $1,744.21 / $1,744.21
| Professional | | $1,550.41 | $1,744.21 | $1,744.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,149.28 / $3,275.25 / $7,045.75
| Facility | | $3,149.28 | $3,275.25 | $7,045.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,249.17 / $2,249.17 / $2,471.85
| Professional | | $2,249.17 | $2,249.17 | $2,471.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,228.71 / $3,939.39 / $3,939.39
| Professional | | $2,228.71 | $3,939.39 | $3,939.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.96 / $1,162.81 / $3,081.44
| Professional | | $813.96 | $1,162.81 | $3,081.44 |