- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,327.86 / $1,327.86 / $10,835.30
| Facility | | $1,327.86 | $1,327.86 | $10,835.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,327.86 / $1,327.86 / $1,380.98
| Professional | | $1,327.86 | $1,327.86 | $1,380.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.38 / $1,416.38 / $1,416.38
| Professional | | $1,416.38 | $1,416.38 | $1,416.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,992.11 / $5,631.75 / $6,436.28
| Facility | | $2,992.11 | $5,631.75 | $6,436.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,054.78 / $2,054.78 / $2,258.23
| Professional | | $2,054.78 | $2,054.78 | $2,258.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,036.05 / $3,598.85 / $3,598.85
| Professional | | $2,036.05 | $3,598.85 | $3,598.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.60 / $1,433.89 / $2,815.06
| Professional | | $743.60 | $1,433.89 | $2,815.06 |