- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $6,456.54 / $8,709.64
| Facility | | $3,548.13 | $6,456.54 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,818.38 / $3,890.45
| Professional | | $2,691.53 | $2,818.38 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,398.83 / $2,691.53
| Facility | | $2,290.87 | $2,398.83 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.60 / $2,818.38 / $5,011.87
| Professional | | $16.60 | $2,818.38 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $4,265.80
| Facility | | $3,162.28 | $3,162.28 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,949.84 / $7,943.28
| Professional | | $1,479.11 | $1,949.84 | $7,943.28 |