- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $3,801.89
| Facility | | $1,479.11 | $2,187.76 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,630.27 / $2,630.27
| Professional | | $2,511.89 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,819.70 / $2,398.83
| Facility | | $575.44 | $1,819.70 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,445.44 / $1,995.26
| Professional | | $776.25 | $1,445.44 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $2,041.74
| Professional | | $30.20 | $30.20 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,258.93 / $1,348.96
| Facility | | $1,174.90 | $1,258.93 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $891.25 / $1,348.96
| Professional | | $812.83 | $891.25 | $1,348.96 |