- 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
- $3,019.95 / $3,981.07 / $7,244.36
| Professional | | $3,019.95 | $3,981.07 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $8,511.38 / $11,481.54
| Facility | | $7,244.36 | $8,511.38 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,466.84 / $5,370.32
| Professional | | $3,019.95 | $4,466.84 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Facility | | $6,456.54 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,981.07 / $8,511.38
| Professional | | $2,754.23 | $3,981.07 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,365.16 / $7,244.36
| Facility | | $1,202.26 | $4,365.16 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,801.89 / $6,606.93
| Professional | | $2,818.38 | $3,801.89 | $6,606.93 |