- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,505.29 / $3,554.64 / $8,551.16
| Facility | | $2,505.29 | $3,554.64 | $8,551.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.16 / $1,227.59 / $1,417.32
| Professional | | $1,127.16 | $1,227.59 | $1,417.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,037.67 / $3,243.84 / $6,733.20
| Facility | | $2,037.67 | $3,243.84 | $6,733.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.00 / $1,116.00 / $1,116.00
| Professional | | $1,116.00 | $1,116.00 | $1,116.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.51 / $478.51 / $851.36
| Facility | | $478.51 | $478.51 | $851.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,588.32 / $2,588.32 / $2,588.32
| Professional | | $2,588.32 | $2,588.32 | $2,588.32 |