- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,371.65 / $2,814.46 / $8,195.70
| Facility | | $2,371.65 | $2,814.46 | $8,195.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,251.57 / $2,371.65 / $2,545.77
| Professional | | $2,251.57 | $2,371.65 | $2,545.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,561.09 / $3,962.76 / $5,914.12
| Professional | | $1,561.09 | $3,962.76 | $5,914.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,716.30 / $5,958.14 / $10,718.89
| Facility | | $1,716.30 | $5,958.14 | $10,718.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,002.09 / $3,002.09 / $14,470.07
| Professional | | $3,002.09 | $3,002.09 | $14,470.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,223.64 / $14,259.93 / $14,259.93
| Facility | | $5,223.64 | $14,259.93 | $14,259.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,010.45 / $15,010.45 / $22,515.68
| Professional | | $15,010.45 | $15,010.45 | $22,515.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.88 / $1,801.25 / $3,002.09
| Professional | | $1,260.88 | $1,801.25 | $3,002.09 |