- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,453.06 / $1,619.13 / $9,844.31
| Facility | | $1,453.06 | $1,619.13 | $9,844.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,619.13 / $1,619.13 / $1,805.95
| Professional | | $1,619.13 | $1,619.13 | $1,805.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,075.80 / $2,075.80 / $2,838.66
| Professional | | $2,075.80 | $2,075.80 | $2,838.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,772.56 / $6,017.74 / $11,835.80
| Facility | | $3,772.56 | $6,017.74 | $11,835.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,385.08 / $2,385.08 / $2,981.34
| Professional | | $2,385.08 | $2,385.08 | $2,981.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.03 / $1,681.40 / $2,615.51
| Facility | | $1,370.03 | $1,681.40 | $2,615.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,075.80 / $2,075.80 / $2,075.80
| Professional | | $2,075.80 | $2,075.80 | $2,075.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.84 / $1,245.48 / $2,490.96
| Professional | | $871.84 | $1,245.48 | $2,490.96 |