- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,538.85 / $1,714.71 / $10,425.40
| Facility | | $1,538.85 | $1,714.71 | $10,425.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,714.71 / $1,714.71 / $1,912.56
| Professional | | $1,714.71 | $1,714.71 | $1,912.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $621.22 / $621.22 / $621.22
| Facility | | $621.22 | $621.22 | $621.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,198.35 / $2,308.27 / $3,033.72
| Professional | | $2,198.35 | $2,308.27 | $3,033.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,995.29 / $5,415.64 / $12,534.57
| Facility | | $3,995.29 | $5,415.64 | $12,534.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,714.71 / $2,198.35 / $2,777.83
| Facility | | $1,714.71 | $2,198.35 | $2,777.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.31 / $1,319.01 / $2,198.35
| Professional | | $923.31 | $1,319.01 | $2,198.35 |