- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,073.80 / $7,762.47
| Facility | | $1,698.24 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,365.16 / $10,232.93
| Professional | | $3,548.13 | $4,365.16 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,162.28 / $6,165.95
| Professional | | $2,630.27 | $3,162.28 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,128.61 / $10,964.78
| Professional | | $3,890.45 | $5,128.61 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,912.51 / $9,772.37
| Professional | | $4,466.84 | $8,912.51 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $16,218.10
| Facility | | $645.65 | $2,344.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,128.61 / $10,964.78
| Professional | | $3,630.78 | $5,128.61 | $10,964.78 |