- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,762.61 / $5,187.10 / $8,015.10
| Facility | | $2,762.61 | $5,187.10 | $8,015.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,882.66 / $2,183.88 / $2,685.92
| Professional | | $1,882.66 | $2,183.88 | $2,685.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,137.76 / $3,137.76 / $3,137.76
| Professional | | $3,137.76 | $3,137.76 | $3,137.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,219.03 / $4,111.72 / $5,692.25
| Facility | | $2,219.03 | $4,111.72 | $5,692.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,008.17 / $2,510.21 / $3,377.01
| Facility | | $2,008.17 | $2,510.21 | $3,377.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,506.13 / $12,500.85
| Professional | | $1,054.29 | $1,506.13 | $12,500.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,506.13 / $3,765.32
| Professional | | $1,054.29 | $1,506.13 | $3,765.32 |