- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,783.68 / $7,104.24 / $10,977.50
| Facility | | $3,783.68 | $7,104.24 | $10,977.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.48 / $2,991.05 / $3,678.64
| Professional | | $2,578.48 | $2,991.05 | $3,678.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,297.47 / $4,297.47 / $4,297.47
| Professional | | $4,297.47 | $4,297.47 | $4,297.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,039.18 / $5,631.42 / $6,961.06
| Facility | | $3,039.18 | $5,631.42 | $6,961.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,819.15 / $3,437.98 / $4,625.14
| Facility | | $2,819.15 | $3,437.98 | $4,625.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.95 / $2,062.79 / $17,121.14
| Professional | | $1,443.95 | $2,062.79 | $17,121.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.95 / $2,062.79 / $5,156.97
| Professional | | $1,443.95 | $2,062.79 | $5,156.97 |