- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,681.13 / $2,385.29 / $5,738.13
| Facility | | $1,681.13 | $2,385.29 | $5,738.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.68 / $2,054.31 / $2,955.68
| Professional | | $1,292.68 | $2,054.31 | $2,955.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,528.30 / $2,180.71 / $4,518.21
| Facility | | $1,528.30 | $2,180.71 | $4,518.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.09 / $1,793.36 / $2,710.53
| Professional | | $1,131.09 | $1,793.36 | $2,710.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $634.80 / $788.60 / $1,569.32
| Facility | | $634.80 | $788.60 | $1,569.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.00 / $4,273.00 / $4,273.00
| Professional | | $740.00 | $4,273.00 | $4,273.00 |