- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,630.27 / $2,630.27
| Facility | | $1,412.54 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,412.54 / $1,548.82
| Professional | | $1,230.27 | $1,412.54 | $1,548.82 |
- 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 / $2,754.23 / $5,248.07
| Facility | | $1,445.44 | $2,754.23 | $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
- $724.44 / $776.25 / $2,187.76
| Professional | | $724.44 | $776.25 | $2,187.76 |