- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,715.35 / $3,715.35
| Facility | | $2,041.74 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,949.84 / $2,344.23
| Professional | | $1,659.59 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Professional | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,981.07 / $7,413.10
| Facility | | $2,089.30 | $3,981.07 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $12,022.64 / $12,022.64
| Professional | | $2,884.03 | $12,022.64 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,479.11
| Facility | | $1,479.11 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,122.02 / $2,511.89
| Professional | | $1,047.13 | $1,122.02 | $2,511.89 |