- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,773.84 / $6,696.86 / $8,110.53
| Facility | | $1,773.84 | $6,696.86 | $8,110.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.11 / $1,060.14 / $5,595.83
| Professional | | $910.11 | $1,060.14 | $5,595.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,134.98 / $2,348.59 / $2,753.84
| Professional | | $2,134.98 | $2,348.59 | $2,753.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,296.77 / $2,590.77 / $3,450.92
| Professional | | $1,296.77 | $2,590.77 | $3,450.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.14 / $1,787.18 / $11,330.00
| Facility | | $1,060.14 | $1,787.18 | $11,330.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.93 / $2,007.88 / $2,741.52
| Professional | | $1,152.93 | $2,007.88 | $2,741.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.53 / $1,944.83 / $2,454.17
| Professional | | $1,115.53 | $1,944.83 | $2,454.17 |