- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,337.65 / $2,805.18 / $4,675.30
| Facility | | $2,337.65 | $2,805.18 | $4,675.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,103.88 / $8,686.70 / $8,686.70
| Professional | | $2,103.88 | $8,686.70 | $8,686.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.15 / $191.92 / $258.19
| Facility | | $158.15 | $191.92 | $258.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.69 / $515.80 / $1,516.78
| Professional | | $424.69 | $515.80 | $1,516.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,489.08 / $1,899.34 / $5,059.84
| Facility | | $1,489.08 | $1,899.34 | $5,059.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.34 / $1,032.54 / $1,367.53
| Professional | | $1,012.34 | $1,032.54 | $1,367.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $981.81 / $2,103.89 / $2,103.89
| Facility | | $981.81 | $2,103.89 | $2,103.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.81 / $981.81 / $1,402.59
| Professional | | $981.81 | $981.81 | $1,402.59 |