- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,211.59 / $2,464.35 / $14,983.20
| Facility | | $2,211.59 | $2,464.35 | $14,983.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,464.35 / $2,527.54 / $2,748.70
| Professional | | $2,464.35 | $2,527.54 | $2,748.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,159.42 / $3,159.42 / $4,320.51
| Professional | | $3,159.42 | $3,159.42 | $4,320.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,105.27 / $6,407.29 / $18,014.34
| Facility | | $2,105.27 | $6,407.29 | $18,014.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,432.75 / $3,159.42 / $3,380.58
| Facility | | $2,432.75 | $3,159.42 | $3,380.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,843.48 / $3,159.42 / $3,159.42
| Facility | | $2,843.48 | $3,159.42 | $3,159.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,737.68 / $2,877.00
| Professional | | $1,326.96 | $1,737.68 | $2,877.00 |