- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $6,165.95 / $11,220.18
| Facility | | $2,884.03 | $6,165.95 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,290.87 / $2,818.38
| Professional | | $1,513.56 | $2,290.87 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Professional | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,495.41 / $6,760.83
| Facility | | $2,691.53 | $5,495.41 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,019.95 / $4,073.80
| Facility | | $2,398.83 | $3,019.95 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $15,135.61
| Professional | | $1,258.93 | $1,819.70 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,019.95 / $3,630.78
| Facility | | $1,258.93 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $3,890.45
| Professional | | $1,258.93 | $1,819.70 | $3,890.45 |