- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,025.60 / $12,022.64
| Facility | | $3,162.28 | $6,025.60 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,630.27 / $3,235.94
| Professional | | $2,137.96 | $2,630.27 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Professional | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,888.44 / $7,413.10
| Facility | | $2,951.21 | $5,888.44 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,235.94 / $4,365.16
| Facility | | $2,570.40 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,949.84 / $16,218.10
| Professional | | $1,348.96 | $1,949.84 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,235.94 / $3,890.45
| Facility | | $1,348.96 | $3,235.94 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,949.84 / $4,168.69
| Professional | | $1,348.96 | $1,949.84 | $4,168.69 |