- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $4,365.16
| Facility | | $1,905.46 | $1,905.46 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,412.54 / $1,905.46
| Professional | | $1,023.29 | $1,412.54 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,162.28 / $5,128.61
| Facility | | $2,344.23 | $3,162.28 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,548.82 / $4,168.69
| Professional | | $977.24 | $1,548.82 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $6,456.54 / $9,549.93
| Facility | | $1,230.27 | $6,456.54 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,548.13 / $4,073.80
| Professional | | $2,570.40 | $3,548.13 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,148.15 / $3,311.31
| Professional | | $912.01 | $1,148.15 | $3,311.31 |