- 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
- $2,454.71 / $2,951.21 / $5,495.41
| Professional | | $2,454.71 | $2,951.21 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,890.45 / $9,549.93
| Professional | | $2,511.89 | $3,890.45 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,890.45 / $4,677.35
| Professional | | $3,019.95 | $3,890.45 | $4,677.35 |
- 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
- $2,089.30 / $2,884.03 / $6,760.83
| Professional | | $2,089.30 | $2,884.03 | $6,760.83 |
- 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
- $2,290.87 / $3,019.95 / $6,918.31
| Professional | | $2,290.87 | $3,019.95 | $6,918.31 |