- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,888.44 / $6,606.93
| Facility | | $3,235.94 | $5,888.44 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,630.27 / $5,888.44
| Professional | | $2,454.71 | $2,630.27 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,365.16 / $4,365.16
| Facility | | $4,168.69 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Professional | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,187.76 / $2,454.71
| Facility | | $2,089.30 | $2,187.76 | $2,454.71 |
- 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
- $2,884.03 / $2,884.03 / $3,890.45
| Facility | | $2,884.03 | $2,884.03 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,949.84 / $7,244.36
| Professional | | $1,348.96 | $1,949.84 | $7,244.36 |