- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $15,848.93 / $15,848.93
| Facility | | $1,949.84 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,949.84 / $2,570.40
| Professional | | $1,819.70 | $1,949.84 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,041.74 / $2,238.72
| Professional | | $1,862.09 | $2,041.74 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,365.16 / $9,772.37
| Facility | | $4,168.69 | $4,365.16 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $5,248.07
| Professional | | $2,951.21 | $2,951.21 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,148.15 / $3,235.94
| Professional | | $1,071.52 | $1,148.15 | $3,235.94 |