- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,742.19 / $3,411.54 / $7,920.26
| Facility | | $2,742.19 | $3,411.54 | $7,920.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.00 / $3,213.93 / $3,618.57
| Professional | | $2,238.00 | $3,213.93 | $3,618.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,846.79 / $2,880.07 / $4,040.24
| Facility | | $1,846.79 | $2,880.07 | $4,040.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,017.94 / $2,726.30 / $2,890.38
| Facility | | $2,017.94 | $2,726.30 | $2,890.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,846.79 / $3,077.68 / $3,970.60
| Facility | | $1,846.79 | $3,077.68 | $3,970.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,371.41 / $7,371.41 / $7,371.41
| Facility | | $7,371.41 | $7,371.41 | $7,371.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,364.00 / $7,664.00 / $36,803.00
| Facility | | $2,364.00 | $7,664.00 | $36,803.00 |