- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $19,498.45 / $19,498.45
| Facility | | $2,398.83 | $19,498.45 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,454.71 / $2,570.40
| Professional | | $2,238.72 | $2,454.71 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,570.40 / $2,818.38
| Professional | | $2,290.87 | $2,570.40 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,370.32 / $12,302.69
| Facility | | $5,248.07 | $5,370.32 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $6,456.54
| Professional | | $3,715.35 | $3,715.35 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,445.44 / $3,981.07
| Professional | | $1,348.96 | $1,445.44 | $3,981.07 |