- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,290.87 / $2,290.87
| Facility | | $1,258.93 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,230.27 / $1,412.54
| Professional | | $1,071.52 | $1,230.27 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $1,819.70
| Professional | | $1,819.70 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,454.71 / $4,570.88
| Facility | | $1,258.93 | $2,454.71 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,244.36
| Professional | | $7,244.36 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $676.08 / $1,905.46
| Professional | | $630.96 | $676.08 | $1,905.46 |