- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $15,488.17
| Facility | | $5,623.41 | $5,623.41 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,548.82 / $1,778.28
| Professional | | $1,202.26 | $1,548.82 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,265.80 / $12,882.50
| Facility | | $3,801.89 | $4,265.80 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $4,265.80
| Professional | | $1,445.44 | $1,445.44 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,918.31 / $9,772.37
| Facility | | $3,630.78 | $6,918.31 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,162.28
| Professional | | $2,570.40 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,890.45 / $5,495.41
| Professional | | $2,238.72 | $3,890.45 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,238.72
| Professional | | $933.25 | $1,318.26 | $2,238.72 |