- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $4,365.16
| Facility | | $1,905.46 | $1,905.46 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,905.46 / $2,454.71
| Professional | | $1,202.26 | $1,905.46 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,754.23
| Professional | | $2,238.72 | $2,238.72 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,691.53 / $3,890.45
| Facility | | $1,174.90 | $2,691.53 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,819.70 / $14,454.40
| Professional | | $645.65 | $1,819.70 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,951.21
| Professional | | $2,290.87 | $2,290.87 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Professional | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,862.09 / $5,495.41
| Professional | | $776.25 | $1,862.09 | $5,495.41 |