- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,248.07 / $13,803.84
| Facility | | $2,570.40 | $5,248.07 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,398.83 / $2,951.21
| Professional | | $1,819.70 | $2,398.83 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,128.61 / $15,135.61
| Facility | | $3,019.95 | $5,128.61 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,698.24 / $3,981.07
| Professional | | $1,513.56 | $1,698.24 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,754.40 / $13,489.63
| Facility | | $1,949.84 | $5,754.40 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,466.84 / $8,317.64
| Professional | | $3,548.13 | $4,466.84 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,019.95 / $3,630.78
| Facility | | $1,819.70 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $3,630.78
| Professional | | $1,258.93 | $1,819.70 | $3,630.78 |