- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,570.88 / $8,511.38
| Facility | | $3,235.94 | $4,570.88 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,905.46 / $3,630.78
| Professional | | $1,513.56 | $1,905.46 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,168.69 / $12,022.64
| Facility | | $3,715.35 | $4,168.69 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,019.95 / $3,981.07
| Professional | | $1,621.81 | $3,019.95 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $4,168.69
| Professional | | $1,995.26 | $2,691.53 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,235.94
| Professional | | $2,884.03 | $2,884.03 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $7,079.46 / $11,220.18
| Facility | | $4,570.88 | $7,079.46 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $4,677.35
| Professional | | $1,778.28 | $2,344.23 | $4,677.35 |