- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $7,943.28 / $15,135.61
| Facility | | $2,238.72 | $7,943.28 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,511.89 / $3,467.37
| Professional | | $2,238.72 | $2,511.89 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,388.44 / $4,466.84
| Professional | | $3,235.94 | $3,388.44 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $7,943.28 / $18,197.01
| Facility | | $2,089.30 | $7,943.28 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,630.27 / $4,073.80
| Facility | | $1,905.46 | $2,630.27 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,235.94 / $3,801.89
| Facility | | $2,884.03 | $3,235.94 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,905.46 / $3,235.94
| Professional | | $1,348.96 | $1,905.46 | $3,235.94 |