- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,368.66 / $1,368.66 / $11,168.30
| Facility | | $1,368.66 | $1,368.66 | $11,168.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,368.66 / $1,368.66 / $1,423.41
| Professional | | $1,368.66 | $1,368.66 | $1,423.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,824.88 / $2,007.37 / $9,968.29
| Professional | | $1,824.88 | $2,007.37 | $9,968.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,965.43 / $3,084.04 / $6,633.88
| Facility | | $2,965.43 | $3,084.04 | $6,633.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.35 / $3,195.93 / $14,218.26
| Professional | | $1,357.35 | $3,195.93 | $14,218.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,098.61 / $3,709.43 / $3,709.43
| Professional | | $2,098.61 | $3,709.43 | $3,709.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.45 / $1,094.93 / $3,952.52
| Professional | | $766.45 | $1,094.93 | $3,952.52 |