- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $7,244.36 / $14,454.40
| Facility | | $1,862.09 | $7,244.36 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,089.30 / $2,951.21
| Professional | | $1,584.89 | $2,089.30 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,995.26 / $10,715.19
| Facility | | $1,348.96 | $1,995.26 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,890.45 / $12,882.50
| Professional | | $3,235.94 | $3,890.45 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $2,238.72
| Professional | | $1,584.89 | $1,584.89 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,398.83 / $2,630.27
| Facility | | $1,122.02 | $2,398.83 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $3,981.07
| Professional | | $933.25 | $1,122.02 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $208.93 / $208.93
| Professional | | $208.93 | $208.93 | $208.93 |