- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,495.41 / $10,715.19
| Facility | | $3,090.30 | $5,495.41 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $6,456.54 / $8,912.51
| Professional | | $2,290.87 | $6,456.54 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,467.37 / $12,589.25
| Facility | | $2,454.71 | $3,467.37 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Professional | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,479.11 / $2,691.53
| Facility | | $676.08 | $1,479.11 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,778.28
| Professional | | $1,698.24 | $1,698.24 | $1,778.28 |