- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $11,481.54
| Facility | | $1,412.54 | $1,412.54 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,412.54 / $1,513.56
| Professional | | $1,318.26 | $1,412.54 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,479.11 / $1,621.81
| Professional | | $1,348.96 | $1,479.11 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $7,079.46
| Facility | | $3,162.28 | $3,162.28 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $3,801.89
| Professional | | $2,137.96 | $2,137.96 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $831.76 / $2,344.23
| Professional | | $776.25 | $831.76 | $2,344.23 |