- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,963.30 / $26,083.75 / $26,083.75
| Facility | | $1,963.30 | $26,083.75 | $26,083.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,099.22 / $1,316.70 / $2,009.22
| Professional | | $1,099.22 | $1,316.70 | $2,009.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,356.84 / $1,520.44 / $1,656.53
| Facility | | $1,356.84 | $1,520.44 | $1,656.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $755.55 / $1,472.47 / $1,472.47
| Professional | | $755.55 | $1,472.47 | $1,472.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,449.04 / $1,449.04 / $1,449.04
| Facility | | $1,449.04 | $1,449.04 | $1,449.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.27 / $1,840.59 / $3,704.14
| Professional | | $1,235.27 | $1,840.59 | $3,704.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,839.22 / $2,839.22 / $2,881.02
| Professional | | $2,839.22 | $2,839.22 | $2,881.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.12 / $1,508.61 / $2,057.08
| Professional | | $980.12 | $1,508.61 | $2,057.08 |