- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,029.31 / $28,046.53 / $28,046.53
| Facility | | $2,029.31 | $28,046.53 | $28,046.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,198.75 / $1,414.69 / $2,168.39
| Professional | | $1,198.75 | $1,414.69 | $2,168.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,309.63 / $1,433.57 / $1,712.23
| Facility | | $1,309.63 | $1,433.57 | $1,712.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.85 / $1,521.98 / $1,521.98
| Professional | | $780.85 | $1,521.98 | $1,521.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,531.60 / $1,531.60 / $1,531.60
| Facility | | $1,531.60 | $1,531.60 | $1,531.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.82 / $1,902.48 / $4,102.20
| Professional | | $1,307.82 | $1,902.48 | $4,102.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.37 / $1,461.87 / $2,106.69
| Professional | | $1,019.37 | $1,461.87 | $2,106.69 |