- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $4,265.80
| Facility | | $1,949.84 | $1,949.84 | $4,265.80 |
- 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
- $2,398.83 / $3,235.94 / $5,248.07
| Facility | | $2,398.83 | $3,235.94 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,818.38 / $3,548.13
| Professional | | $1,148.15 | $2,818.38 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,162.28 / $11,220.18
| Facility | | $1,258.93 | $3,162.28 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,630.78 / $4,168.69
| Professional | | $2,630.27 | $3,630.78 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,174.90 / $3,388.44
| Professional | | $933.25 | $1,174.90 | $3,388.44 |