- 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
- $2,041.74 / $2,344.23 / $5,623.41
| Professional | | $2,041.74 | $2,344.23 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,548.13 / $8,912.51
| Professional | | $2,137.96 | $3,548.13 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,467.37 / $4,265.80
| Professional | | $2,570.40 | $3,467.37 | $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
- $2,041.74 / $2,691.53 / $9,332.54
| Professional | | $2,041.74 | $2,691.53 | $9,332.54 |
- 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
- $1,995.26 / $2,691.53 / $5,370.32
| Professional | | $1,995.26 | $2,691.53 | $5,370.32 |