- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,548.13 / $3,981.07
| Facility | | $1,949.84 | $3,548.13 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,548.82 / $3,548.13
| Professional | | $1,288.25 | $1,548.82 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Professional | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,318.26
| Facility | | $1,258.93 | $1,258.93 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $39.81 / $50.12
| Professional | | $21.38 | $39.81 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,344.23
| Facility | | $1,737.80 | $1,737.80 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $4,365.16
| Professional | | $812.83 | $1,174.90 | $4,365.16 |