- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $7,413.10 / $14,125.38
| Facility | | $2,089.30 | $7,413.10 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,398.83 / $2,630.27
| Professional | | $1,513.56 | $2,398.83 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,235.94 / $4,168.69
| Professional | | $3,019.95 | $3,235.94 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $7,585.78 / $16,982.44
| Facility | | $1,949.84 | $7,585.78 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,691.53 / $5,495.41
| Facility | | $2,238.72 | $2,691.53 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,019.95 / $3,630.78
| Facility | | $2,691.53 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $3,019.95
| Professional | | $1,258.93 | $1,819.70 | $3,019.95 |