- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $7,413.10 / $14,454.40
| Facility | | $2,137.96 | $7,413.10 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,344.23 / $2,951.21
| Professional | | $2,137.96 | $2,344.23 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,235.94 / $4,265.80
| Professional | | $3,019.95 | $3,235.94 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $7,762.47 / $17,378.01
| Facility | | $1,949.84 | $7,762.47 | $17,378.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,754.23 / $5,495.41
| Facility | | $2,290.87 | $2,754.23 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,019.95 / $3,630.78
| Facility | | $2,754.23 | $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 |