- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,694.77 / $5,059.70 / $7,818.25
| Facility | | $2,694.77 | $5,059.70 | $7,818.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,958.85 / $2,130.25 / $2,619.96
| Professional | | $1,958.85 | $2,130.25 | $2,619.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.70 / $3,060.71 / $3,060.71
| Professional | | $3,060.70 | $3,060.71 | $3,060.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,164.52 / $4,010.73 / $5,552.40
| Facility | | $2,164.52 | $4,010.73 | $5,552.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,958.85 / $2,448.56 / $3,294.08
| Facility | | $1,958.85 | $2,448.56 | $3,294.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.40 / $1,469.14 / $12,193.83
| Professional | | $1,028.40 | $1,469.14 | $12,193.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.40 / $1,469.14 / $3,917.70
| Professional | | $1,028.40 | $1,469.14 | $3,917.70 |