- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,513.56 / $2,398.83
| Facility | | $1,023.29 | $1,513.56 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,818.38 / $5,128.61
| Professional | | $2,238.72 | $2,818.38 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $11,481.54 / $15,488.17
| Facility | | $9,549.93 | $11,481.54 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,311.31 / $3,981.07
| Professional | | $2,454.71 | $3,311.31 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $4,570.88
| Facility | | $4,570.88 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,818.38 / $6,025.60
| Professional | | $1,905.46 | $2,818.38 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,365.16 / $7,244.36
| Facility | | $1,479.11 | $4,365.16 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $4,570.88
| Professional | | $1,995.26 | $2,691.53 | $4,570.88 |