- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,715.35 / $13,182.57
| Facility | | $2,137.96 | $3,715.35 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,630.78 / $3,981.07
| Professional | | $3,548.13 | $3,630.78 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $4,365.16 / $8,709.64
| Facility | | $1,096.48 | $4,365.16 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $3,801.89 / $4,365.16
| Professional | | $380.19 | $3,801.89 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,890.45 / $3,890.45
| Facility | | $933.25 | $3,890.45 | $3,890.45 |
- 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
- $676.08 / $776.25 / $1,380.38
| Facility | | $676.08 | $776.25 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,801.89 / $4,570.88
| Professional | | $3,715.35 | $3,801.89 | $4,570.88 |