- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,412.54
| Facility | | $1,202.26 | $1,202.26 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $1,737.80
| Professional | | $1,071.52 | $1,202.26 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,659.59
| Facility | | $1,380.38 | $1,380.38 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,479.11
| Professional | | $1,479.11 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $2,187.76 / $2,187.76
| Facility | | $34.67 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,737.80 / $7,079.46
| Professional | | $1,096.48 | $1,737.80 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $8,511.38
| Facility | | $5,754.40 | $5,754.40 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,318.26 / $2,041.74
| Professional | | $977.24 | $1,318.26 | $2,041.74 |