- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,370.32 / $10,715.19
| Facility | | $3,090.30 | $5,370.32 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,819.70 / $3,019.95
| Professional | | $1,148.15 | $1,819.70 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,570.40 / $3,715.35
| Professional | | $1,905.46 | $2,570.40 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Professional | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Professional | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,754.40 / $12,302.69
| Facility | | $2,630.27 | $5,754.40 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,884.03 / $4,786.30
| Professional | | $2,089.30 | $2,884.03 | $4,786.30 |