- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $6,456.54 / $7,079.46
| Facility | | $3,467.37 | $6,456.54 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,818.38 / $6,456.54
| Professional | | $2,630.27 | $2,818.38 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,398.83 / $2,630.27
| Facility | | $2,290.87 | $2,398.83 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Professional | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $4,168.69
| Facility | | $3,162.28 | $3,162.28 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $7,762.47
| Professional | | $1,479.11 | $2,089.30 | $7,762.47 |