- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $4,073.80
| Facility | | $1,862.09 | $1,862.09 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,380.38 / $1,819.70
| Professional | | $1,023.29 | $1,380.38 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,090.30 / $5,011.87
| Facility | | $2,290.87 | $3,090.30 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $8,317.64 / $9,549.93
| Professional | | $954.99 | $8,317.64 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $10,715.19
| Facility | | $1,202.26 | $1,202.26 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,388.44 / $4,073.80
| Professional | | $1,949.84 | $3,388.44 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,122.02 / $3,235.94
| Professional | | $891.25 | $1,122.02 | $3,235.94 |