- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,309.57 / $13,182.57
| Facility | | $3,162.28 | $6,309.57 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,041.74 / $2,691.53
| Professional | | $1,445.44 | $2,041.74 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,265.80
| Professional | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,041.74 / $5,754.40
| Facility | | $1,096.48 | $2,041.74 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,951.21 / $16,218.10
| Professional | | $2,238.72 | $2,951.21 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,445.44 / $8,128.31
| Facility | | $912.01 | $1,445.44 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,754.23 / $3,715.35
| Professional | | $2,187.76 | $2,754.23 | $3,715.35 |