- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,162.28 / $11,220.18
| Facility | | $2,344.23 | $3,162.28 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,862.09 / $2,818.38
| Professional | | $1,318.26 | $1,862.09 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $3,162.28
| Professional | | $2,511.89 | $2,511.89 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,995.26 / $2,187.76
| Facility | | $933.25 | $1,995.26 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,000.00 / $2,454.71
| Professional | | $870.96 | $1,000.00 | $2,454.71 |