- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,419.39 / $4,542.67 / $7,019.33
| Facility | | $2,419.39 | $4,542.67 | $7,019.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.76 / $1,912.56 / $2,198.35
| Professional | | $1,648.76 | $1,912.56 | $2,198.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,747.94 / $2,747.94 / $2,747.94
| Professional | | $2,747.94 | $2,747.94 | $2,747.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,943.34 / $3,600.90 / $4,984.56
| Facility | | $1,943.34 | $3,600.90 | $4,984.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,758.68 / $2,198.35 / $2,957.46
| Facility | | $1,758.68 | $2,198.35 | $2,957.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.31 / $1,319.01 / $10,947.78
| Professional | | $923.31 | $1,319.01 | $10,947.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.31 / $1,319.01 / $3,517.36
| Professional | | $923.31 | $1,319.01 | $3,517.36 |