- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $6,606.93 / $12,022.64
| Facility | | $3,090.30 | $6,606.93 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,570.40 / $3,235.94
| Professional | | $2,137.96 | $2,570.40 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Professional | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,888.44 / $7,244.36
| Facility | | $2,884.03 | $5,888.44 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,235.94 / $4,265.80
| Facility | | $2,570.40 | $3,235.94 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,905.46 / $15,848.93
| Professional | | $1,348.96 | $1,905.46 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,235.94 / $3,801.89
| Facility | | $1,348.96 | $3,235.94 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,905.46 / $4,168.69
| Professional | | $1,348.96 | $1,905.46 | $4,168.69 |