- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $11,220.18 / $18,197.01
| Facility | | $2,344.23 | $11,220.18 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,089.30 / $2,511.89
| Professional | | $2,041.74 | $2,089.30 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,754.23 / $3,981.07
| Facility | | $1,380.38 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,344.23 / $2,754.23
| Professional | | $1,698.24 | $2,344.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $9,332.54 / $12,882.50
| Professional | | $6,606.93 | $9,332.54 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,818.38 / $3,981.07
| Facility | | $1,698.24 | $2,818.38 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $10,232.93 / $13,182.57
| Professional | | $2,754.23 | $10,232.93 | $13,182.57 |