- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,442.73 / $2,721.91 / $16,549.20
| Facility | | $2,442.73 | $2,721.91 | $16,549.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.91 / $2,721.91 / $3,035.98
| Professional | | $2,721.91 | $2,721.91 | $3,035.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,559.44 / $3,664.11 / $3,946.76
| Facility | | $3,559.44 | $3,664.11 | $3,946.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,489.63 / $3,664.11 / $4,815.68
| Professional | | $3,489.63 | $3,664.11 | $4,815.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,342.05 / $8,596.70 / $19,897.18
| Facility | | $6,342.05 | $8,596.70 | $19,897.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,721.91 / $3,489.63 / $4,409.49
| Facility | | $2,721.91 | $3,489.63 | $4,409.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.00 / $1,500.00 / $1,500.00
| Professional | | $1,500.00 | $1,500.00 | $1,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.64 / $1,744.82 / $3,177.69
| Professional | | $1,465.64 | $1,744.82 | $3,177.69 |