- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $10,715.19
| Facility | | $1,318.26 | $1,318.26 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,318.26 / $1,412.54
| Professional | | $1,230.27 | $1,318.26 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,412.54 / $1,513.56
| Professional | | $1,258.93 | $1,412.54 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $6,760.83
| Facility | | $2,951.21 | $2,951.21 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $3,548.13
| Professional | | $1,995.26 | $1,995.26 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Facility | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $794.33 / $2,187.76
| Professional | | $741.31 | $794.33 | $2,187.76 |