- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,882.14 / $1,882.14 / $1,882.14
| Facility | | $1,882.14 | $1,882.14 | $1,882.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.42 / $2,569.28 / $9,310.11
| Professional | | $1,675.42 | $2,569.28 | $9,310.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.11 / $2,725.48 / $3,247.45
| Professional | | $2,044.11 | $2,725.48 | $3,247.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.07 / $1,743.07 / $1,743.07
| Facility | | $1,743.07 | $1,743.07 | $1,743.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.44 / $1,272.44 / $4,047.35
| Professional | | $1,272.44 | $1,272.44 | $4,047.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,729.48 / $3,411.85 / $5,117.77
| Professional | | $2,729.48 | $3,411.85 | $5,117.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $898.44 / $898.44 / $2,564.02
| Facility | | $898.44 | $898.44 | $2,564.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.44 / $1,743.07 / $3,998.26
| Professional | | $1,272.44 | $1,743.07 | $3,998.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.72 / $1,391.68 / $2,129.64
| Professional | | $1,286.72 | $1,391.68 | $2,129.64 |