- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,025.60 / $13,489.63
| Facility | | $3,890.45 | $6,025.60 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,162.28 / $3,715.35
| Professional | | $2,630.27 | $3,162.28 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $11,748.98
| Facility | | $3,890.45 | $3,890.45 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $3,235.94
| Professional | | $1,548.82 | $1,548.82 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,890.45 / $8,709.64
| Facility | | $2,511.89 | $3,890.45 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,548.13 / $5,623.41
| Professional | | $1,778.28 | $3,548.13 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Facility | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,344.23 / $3,890.45
| Professional | | $1,621.81 | $2,344.23 | $3,890.45 |