- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,248.07 / $10,471.29
| Facility | | $2,398.83 | $5,248.07 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $4,466.84 / $5,370.32
| Professional | | $1,174.90 | $4,466.84 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Professional | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $6,760.83 / $17,378.01
| Facility | | $1,905.46 | $6,760.83 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,230.27 / $42,657.95
| Professional | | $933.25 | $1,230.27 | $42,657.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $8,912.51 / $15,848.93
| Facility | | $2,570.40 | $8,912.51 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,288.25 / $2,454.71
| Professional | | $891.25 | $1,288.25 | $2,454.71 |