- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,425.15 / $1,425.15 / $11,629.20
| Facility | | $1,425.15 | $1,425.15 | $11,629.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.15 / $1,425.15 / $1,482.16
| Professional | | $1,425.15 | $1,425.15 | $1,482.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,520.16 / $1,520.16 / $1,520.16
| Professional | | $1,520.16 | $1,520.16 | $1,520.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,211.34 / $6,044.21 / $6,907.66
| Facility | | $3,211.34 | $6,044.21 | $6,907.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,205.37 / $2,205.37 / $2,423.71
| Professional | | $2,205.37 | $2,205.37 | $2,423.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,185.23 / $3,862.54 / $3,862.54
| Professional | | $2,185.23 | $3,862.54 | $3,862.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.08 / $1,140.11 / $3,021.32
| Professional | | $798.08 | $1,140.11 | $3,021.32 |