- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,292.05 / $5,271.78 / $10,844.40
| Facility | | $3,292.05 | $5,271.78 | $10,844.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.10 / $3,175.86 / $4,453.95
| Professional | | $2,711.10 | $3,175.86 | $4,453.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,747.90 / $4,205.78 / $13,400.58
| Facility | | $3,747.90 | $4,205.78 | $13,400.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.20 / $1,890.02 / $4,954.01
| Professional | | $1,549.20 | $1,890.02 | $4,954.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,675.48 / $6,646.07 / $11,328.53
| Facility | | $3,675.48 | $6,646.07 | $11,328.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,827.50 / $3,573.39 / $6,597.17
| Professional | | $1,827.50 | $3,573.39 | $6,597.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,485.70 / $3,485.70 / $3,485.70
| Facility | | $3,485.70 | $3,485.70 | $3,485.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $2,323.80 / $4,453.95
| Professional | | $1,626.66 | $2,323.80 | $4,453.95 |