- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,467.37 / $3,890.45
| Facility | | $1,905.46 | $3,467.37 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,513.56 / $2,187.76
| Professional | | $1,412.54 | $1,513.56 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Professional | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,288.25
| Facility | | $1,230.27 | $1,230.27 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $21.38 / $50.12
| Professional | | $16.98 | $21.38 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $2,290.87
| Facility | | $1,698.24 | $1,698.24 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,148.15 / $4,265.80
| Professional | | $794.33 | $1,148.15 | $4,265.80 |