- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,168.69 / $5,370.32
| Facility | | $3,630.78 | $4,168.69 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,951.21 / $4,168.69
| Professional | | $2,137.96 | $2,951.21 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.88 / $70.79 / $95.50
| Facility | | $58.88 | $70.79 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,344.23 / $3,388.44
| Professional | | $2,187.76 | $2,344.23 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,951.21 / $7,762.47
| Facility | | $2,344.23 | $2,951.21 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Professional | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,235.94 / $3,630.78
| Facility | | $1,513.56 | $3,235.94 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $2,137.96
| Professional | | $1,513.56 | $1,513.56 | $2,137.96 |