- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $18,197.01
| Facility | | $2,238.72 | $2,238.72 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,238.72 / $2,454.71
| Professional | | $1,513.56 | $2,238.72 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,398.83 / $2,630.27
| Professional | | $2,137.96 | $2,398.83 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,128.61 / $11,481.54
| Facility | | $4,897.79 | $5,128.61 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $6,165.95
| Professional | | $3,467.37 | $3,467.37 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,348.96 / $3,715.35
| Professional | | $1,258.93 | $1,348.96 | $3,715.35 |