- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $5,248.07
| Facility | | $2,290.87 | $2,290.87 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,698.24 / $2,290.87
| Professional | | $1,230.27 | $1,698.24 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,801.89 / $6,165.95
| Facility | | $2,818.38 | $3,801.89 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,290.87 / $5,128.61
| Professional | | $1,023.29 | $2,290.87 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $7,762.47 / $11,481.54
| Facility | | $1,479.11 | $7,762.47 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,168.69 / $4,897.79
| Professional | | $2,398.83 | $4,168.69 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,380.38 / $3,981.07
| Professional | | $1,096.48 | $1,380.38 | $3,981.07 |