- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $7,762.47
| Facility | | $3,467.37 | $3,467.37 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $3,388.44
| Professional | | $1,778.28 | $1,778.28 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,754.40 / $9,549.93
| Facility | | $4,365.16 | $5,754.40 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,467.37 / $4,677.35
| Professional | | $1,584.89 | $3,467.37 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $19,952.62
| Facility | | $2,290.87 | $2,290.87 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,456.54 / $7,585.78
| Professional | | $4,677.35 | $6,456.54 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,089.30 / $6,165.95
| Professional | | $1,698.24 | $2,089.30 | $6,165.95 |