- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,495.41 / $10,964.78
| Facility | | $2,818.38 | $5,495.41 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,344.23 / $2,951.21
| Professional | | $1,949.84 | $2,344.23 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Professional | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,370.32 / $5,888.44
| Facility | | $2,630.27 | $5,370.32 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,951.21 / $3,890.45
| Facility | | $2,344.23 | $2,951.21 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $14,454.40
| Professional | | $1,230.27 | $1,737.80 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,951.21 / $3,467.37
| Facility | | $1,230.27 | $2,951.21 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $3,801.89
| Professional | | $1,230.27 | $1,737.80 | $3,801.89 |