- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,457.41 / $1,457.41 / $11,892.40
| Facility | | $1,457.41 | $1,457.41 | $11,892.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.41 / $1,457.41 / $1,515.70
| Professional | | $1,457.41 | $1,457.41 | $1,515.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.57 / $1,787.75 / $1,787.75
| Professional | | $1,554.57 | $1,787.75 | $1,787.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,157.73 / $3,284.03 / $7,064.79
| Facility | | $3,157.73 | $3,284.03 | $7,064.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,255.00 / $2,255.00 / $2,478.27
| Professional | | $2,255.00 | $2,255.00 | $2,478.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,234.69 / $3,949.96 / $3,949.96
| Professional | | $2,234.69 | $3,949.96 | $3,949.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.15 / $1,165.93 / $2,429.01
| Professional | | $816.15 | $1,165.93 | $2,429.01 |