- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,336.09 / $1,336.09 / $2,839.19
| Facility | | $1,336.09 | $1,336.09 | $2,839.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.23 / $1,082.23 / $1,082.23
| Professional | | $1,082.23 | $1,082.23 | $1,082.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,404.08 / $8,547.50 / $9,962.95
| Facility | | $7,404.08 | $8,547.50 | $9,962.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.20 / $699.20 / $1,135.67
| Professional | | $699.20 | $699.20 | $1,135.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.09 / $1,336.09 / $1,349.45
| Professional | | $1,336.09 | $1,336.09 | $1,349.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,336.09 / $1,336.09 / $2,164.46
| Facility | | $1,336.09 | $1,336.09 | $2,164.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.23 / $1,082.23 / $1,336.09
| Professional | | $1,082.23 | $1,082.23 | $1,336.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.65 / $801.65 / $2,004.14
| Professional | | $801.65 | $801.65 | $2,004.14 |