- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $7,244.36 / $12,882.50
| Facility | | $3,388.44 | $7,244.36 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,884.03 / $3,467.37
| Professional | | $2,290.87 | $2,884.03 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Professional | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,309.57 / $7,943.28
| Facility | | $3,162.28 | $6,309.57 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,467.37 / $4,677.35
| Facility | | $2,818.38 | $3,467.37 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $17,378.01
| Professional | | $1,479.11 | $2,089.30 | $17,378.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,467.37 / $4,168.69
| Facility | | $1,479.11 | $3,467.37 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $4,570.88
| Professional | | $1,479.11 | $2,089.30 | $4,570.88 |