- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,981.07 / $6,309.57
| Facility | | $3,388.44 | $3,981.07 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,890.45 / $4,365.16
| Professional | | $2,454.71 | $3,890.45 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $6,606.93 / $6,606.93
| Professional | | $1,819.70 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $58.88 / $70.79
| Professional | | $50.12 | $58.88 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Professional | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $12,589.25 / $12,589.25
| Facility | | $8,511.38 | $12,589.25 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,606.93 / $6,606.93
| Professional | | $5,128.61 | $6,606.93 | $6,606.93 |