- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,918.31 / $11,748.98
| Facility | | $4,466.84 | $6,918.31 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,388.44 / $6,456.54
| Professional | | $2,884.03 | $3,388.44 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,128.61 / $12,589.25
| Professional | | $2,951.21 | $5,128.61 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,897.79 / $6,165.95
| Professional | | $3,630.78 | $4,897.79 | $6,165.95 |
- 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
- $2,951.21 / $3,981.07 / $13,182.57
| Professional | | $2,951.21 | $3,981.07 | $13,182.57 |
- 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
- $2,754.23 / $3,890.45 / $7,413.10
| Professional | | $2,754.23 | $3,890.45 | $7,413.10 |