- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,334.76 / $1,334.76 / $1,334.76
| Facility | | $1,334.76 | $1,334.76 | $1,334.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.10 / $1,109.91 / $1,530.94
| Professional | | $972.10 | $1,109.91 | $1,530.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,530.37 / $2,004.98 / $2,272.07
| Facility | | $1,530.37 | $2,004.98 | $2,272.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.07 / $1,780.45 / $1,780.45
| Professional | | $203.07 | $1,780.45 | $1,780.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,947.91 / $3,947.91 / $3,947.91
| Facility | | $3,947.91 | $3,947.91 | $3,947.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.66 / $1,322.82 / $2,463.46
| Professional | | $1,035.66 | $1,322.82 | $2,463.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $755.91 / $1,897.73 / $2,810.88
| Professional | | $755.91 | $1,897.73 | $2,810.88 |