- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,238.72 / $2,238.72
| Facility | | $1,412.54 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,905.46 / $2,570.40
| Professional | | $1,047.13 | $1,905.46 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Professional | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $20,417.38
| Facility | | $2,884.03 | $2,884.03 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $794.33 / $2,344.23
| Professional | | $457.09 | $794.33 | $2,344.23 |