- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,679.35 / $4,039.54 / $10,775.50
| Facility | | $3,679.35 | $4,039.54 | $10,775.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.69 / $2,546.50 / $2,711.10
| Professional | | $2,052.69 | $2,546.50 | $2,711.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $658.72 / $4,694.46 / $9,585.68
| Facility | | $658.72 | $4,694.46 | $9,585.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,742.85 / $2,323.80 / $5,407.86
| Professional | | $1,742.85 | $2,323.80 | $5,407.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,876.87 / $8,287.99 / $15,816.40
| Facility | | $3,876.87 | $8,287.99 | $15,816.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,453.95 / $7,056.61 / $9,566.31
| Professional | | $4,453.95 | $7,056.61 | $9,566.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,781.58 / $2,323.80 / $6,796.73
| Professional | | $1,781.58 | $2,323.80 | $6,796.73 |