- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,677.35 / $9,332.54
| Facility | | $2,454.71 | $4,677.35 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,041.74 / $2,511.89
| Professional | | $1,659.59 | $2,041.74 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,570.88 / $5,754.40
| Facility | | $2,290.87 | $4,570.88 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,511.89 / $3,388.44
| Facility | | $1,995.26 | $2,511.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $12,589.25
| Professional | | $1,047.13 | $1,513.56 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,511.89 / $3,019.95
| Facility | | $1,047.13 | $2,511.89 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $3,235.94
| Professional | | $1,047.13 | $1,513.56 | $3,235.94 |