- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $6,760.83 / $13,489.63
| Facility | | $3,467.37 | $6,760.83 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,884.03 / $3,630.78
| Professional | | $2,398.83 | $2,884.03 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Professional | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $6,606.93 / $8,128.31
| Facility | | $3,235.94 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,630.78 / $4,897.79
| Facility | | $2,884.03 | $3,630.78 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $18,197.01
| Professional | | $1,513.56 | $2,137.96 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,630.78 / $4,365.16
| Facility | | $1,513.56 | $3,630.78 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $4,677.35
| Professional | | $1,513.56 | $2,137.96 | $4,677.35 |