- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $5,623.41
| Facility | | $3,467.37 | $3,467.37 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,754.23 / $3,388.44
| Professional | | $2,238.72 | $2,754.23 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $1,698.24 / $2,290.87
| Professional | | $239.88 | $1,698.24 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $7,943.28
| Facility | | $7,943.28 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,265.80 / $7,585.78
| Professional | | $3,467.37 | $4,265.80 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,818.38 / $3,388.44
| Professional | | $2,238.72 | $2,818.38 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,467.37 / $6,165.95
| Professional | | $2,089.30 | $3,467.37 | $6,165.95 |