- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,938.01 / $2,228.71 / $3,876.02
| Facility | | $1,938.01 | $2,228.71 | $3,876.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,511.65 / $2,228.71 / $2,228.71
| Professional | | $1,511.65 | $2,228.71 | $2,228.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.67 / $69.98 / $94.15
| Facility | | $57.67 | $69.98 | $94.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.48 / $4,235.54 / $4,997.93
| Professional | | $1,257.48 | $4,235.54 | $4,997.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,234.52 / $1,574.64 / $4,194.83
| Facility | | $1,234.52 | $1,574.64 | $4,194.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.96 / $813.96 / $1,938.01
| Professional | | $813.96 | $813.96 | $1,938.01 |