- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $15,488.17
| Facility | | $1,862.09 | $1,862.09 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,905.46 / $2,041.74
| Professional | | $1,737.80 | $1,905.46 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,995.26 / $2,187.76
| Professional | | $1,819.70 | $1,995.26 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,265.80 / $9,549.93
| Facility | | $4,073.80 | $4,265.80 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $5,128.61
| Professional | | $2,884.03 | $2,884.03 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,258.93 / $3,467.37
| Professional | | $1,047.13 | $1,258.93 | $3,467.37 |