- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,265.80 / $5,495.41
| Facility | | $3,715.35 | $4,265.80 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,818.38 / $3,548.13
| Professional | | $1,995.26 | $2,818.38 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $891.25
| Facility | | $549.54 | $660.69 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $309.03 / $2,398.83
| Professional | | $218.78 | $309.03 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,019.95 / $7,943.28
| Facility | | $2,398.83 | $3,019.95 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Professional | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,311.31 / $3,715.35
| Facility | | $1,548.82 | $3,311.31 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,187.76
| Professional | | $1,548.82 | $1,548.82 | $2,187.76 |