- 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
- $1,778.28 / $2,754.23 / $5,128.61
| Professional | | $1,778.28 | $2,754.23 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,388.44 / $8,912.51
| Professional | | $2,041.74 | $3,388.44 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,548.13 / $4,265.80
| Professional | | $2,754.23 | $3,548.13 | $4,265.80 |
- 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
- $1,949.84 / $2,754.23 / $6,309.57
| Professional | | $1,949.84 | $2,754.23 | $6,309.57 |
- 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
- $2,089.30 / $2,818.38 / $6,456.54
| Professional | | $2,089.30 | $2,818.38 | $6,456.54 |