- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $4,570.88 / $8,128.31
| Facility | | $2,137.96 | $4,570.88 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,778.28 / $2,187.76
| Professional | | $1,513.56 | $1,778.28 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,981.07 / $5,011.87
| Facility | | $1,995.26 | $3,981.07 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,187.76 / $2,951.21
| Facility | | $1,778.28 | $2,187.76 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $10,964.78
| Professional | | $933.25 | $1,318.26 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,187.76 / $2,630.27
| Facility | | $933.25 | $2,187.76 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,884.03
| Professional | | $933.25 | $1,318.26 | $2,884.03 |