- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,981.07 / $7,943.28
| Facility | | $2,041.74 | $3,981.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,737.80 / $2,137.96
| Professional | | $1,412.54 | $1,737.80 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Professional | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,890.45 / $4,786.30
| Facility | | $1,905.46 | $3,890.45 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,137.96 / $2,884.03
| Facility | | $1,698.24 | $2,137.96 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,288.25 / $10,471.29
| Professional | | $891.25 | $1,288.25 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,137.96 / $2,570.40
| Facility | | $891.25 | $2,137.96 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,288.25 / $2,754.23
| Professional | | $891.25 | $1,288.25 | $2,754.23 |