- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,997.22 / $10,465.40 / $13,720.90
| Facility | | $1,997.22 | $10,465.40 | $13,720.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.08 / $1,775.30 / $2,596.38
| Professional | | $1,459.08 | $1,775.30 | $2,596.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,896.80 / $1,950.85 / $6,114.46
| Facility | | $1,896.80 | $1,950.85 | $6,114.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $2,549.86 / $3,187.33
| Professional | | $2,549.86 | $2,549.86 | $3,187.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,285.69 / $2,552.00 / $2,662.96
| Facility | | $2,285.69 | $2,552.00 | $2,662.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.63 / $1,736.35 / $1,887.37
| Professional | | $1,698.63 | $1,736.35 | $1,887.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $932.03 / $1,331.48
| Professional | | $932.03 | $932.03 | $1,331.48 |