- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $2,137.96
| Facility | | $1,230.27 | $1,584.89 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,230.27 / $1,318.26
| Professional | | $1,174.90 | $1,230.27 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,659.59
| Professional | | $1,258.93 | $1,258.93 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $6,606.93 / $6,606.93
| Facility | | $1,479.11 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.26 / $12.88 / $1,202.26
| Facility | | $1.26 | $12.88 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,288.25 / $1,288.25
| Professional | | $758.58 | $1,288.25 | $1,288.25 |