- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,918.31 / $11,748.98
| Facility | | $4,365.16 | $6,918.31 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,548.82 / $2,884.03
| Professional | | $1,288.25 | $1,548.82 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,089.30 / $5,011.87
| Professional | | $1,318.26 | $2,089.30 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,089.30 / $2,454.71
| Professional | | $1,584.89 | $2,089.30 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,513.56 / $3,630.78
| Professional | | $1,096.48 | $1,513.56 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,888.44 / $10,471.29
| Facility | | $1,698.24 | $5,888.44 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $3,630.78
| Professional | | $1,230.27 | $1,584.89 | $3,630.78 |