- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.25 / $1,453.31 / $8,836.12
| Facility | | $1,304.25 | $1,453.31 | $8,836.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.31 / $1,453.31 / $1,490.58
| Professional | | $1,453.31 | $1,453.31 | $1,490.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,863.22 / $1,863.22 / $2,547.94
| Professional | | $1,863.22 | $1,863.22 | $2,547.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,386.21 / $4,590.03 / $10,623.68
| Facility | | $3,386.21 | $4,590.03 | $10,623.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.26 / $1,863.22 / $2,310.39
| Facility | | $1,304.26 | $1,863.22 | $2,310.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $1,117.93 / $1,863.22
| Professional | | $782.55 | $1,117.93 | $1,863.22 |