- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $12,022.64
| Facility | | $1,318.26 | $1,318.26 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,318.26 / $1,412.54
| Professional | | $1,230.27 | $1,318.26 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,548.82 / $1,698.24
| Professional | | $1,412.54 | $1,548.82 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,311.31 / $7,413.10
| Facility | | $2,884.03 | $3,311.31 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $3,981.07
| Professional | | $2,238.72 | $2,238.72 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $794.33 / $2,187.76
| Professional | | $741.31 | $794.33 | $2,187.76 |