- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Facility | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $1,949.84
| Professional | | $933.25 | $1,318.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,818.38 / $2,884.03
| Professional | | $2,398.83 | $2,818.38 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,511.89 / $3,162.28
| Professional | | $2,454.71 | $2,511.89 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,548.82 / $11,220.18
| Facility | | $1,202.26 | $1,548.82 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,047.13 / $1,905.46
| Professional | | $851.14 | $1,047.13 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $1,047.13 / $1,380.38
| Facility | | $138.04 | $1,047.13 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,258.93 / $2,454.71
| Professional | | $831.76 | $1,258.93 | $2,454.71 |