- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,648.76 / $1,648.76 / $13,453.90
| Facility | | $1,648.76 | $1,648.76 | $13,453.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.76 / $1,648.76 / $1,714.71
| Professional | | $1,648.76 | $1,648.76 | $1,714.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.68 / $2,022.48 / $2,022.48
| Professional | | $1,758.68 | $2,022.48 | $2,022.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,572.33 / $3,715.22 / $7,992.08
| Facility | | $3,572.33 | $3,715.22 | $7,992.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,551.17 / $2,551.17 / $2,803.76
| Professional | | $2,551.17 | $2,551.17 | $2,803.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,528.10 / $4,468.59 / $4,468.59
| Professional | | $2,528.10 | $4,468.59 | $4,468.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $923.31 / $923.31 / $923.31
| Facility | | $923.31 | $923.31 | $923.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.31 / $1,319.01 / $3,495.38
| Professional | | $923.31 | $1,319.01 | $3,495.38 |