- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,397.42 / $1,397.42 / $11,402.90
| Facility | | $1,397.42 | $1,397.42 | $11,402.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,397.42 / $1,397.42 / $1,453.31
| Professional | | $1,397.42 | $1,397.42 | $1,453.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,490.58 / $1,490.58 / $1,490.58
| Professional | | $1,490.58 | $1,490.58 | $1,490.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,148.83 / $5,926.51 / $6,773.15
| Facility | | $3,148.83 | $5,926.51 | $6,773.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,162.40 / $2,162.40 / $2,376.50
| Professional | | $2,162.40 | $2,162.40 | $2,376.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,142.69 / $3,787.37 / $3,787.37
| Professional | | $2,142.69 | $3,787.37 | $3,787.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $1,117.93 / $2,962.52
| Professional | | $782.55 | $1,117.93 | $2,962.52 |