- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,244.36 / $14,454.40
| Facility | | $3,715.35 | $7,244.36 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,162.28 / $3,890.45
| Professional | | $2,570.40 | $3,162.28 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Professional | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $7,079.46 / $8,709.64
| Facility | | $3,467.37 | $7,079.46 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,890.45 / $5,248.07
| Facility | | $3,090.30 | $3,890.45 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,344.23 / $19,498.45
| Professional | | $1,621.81 | $2,344.23 | $19,498.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,890.45 / $4,677.35
| Facility | | $1,621.81 | $3,890.45 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,344.23 / $5,011.87
| Professional | | $1,621.81 | $2,344.23 | $5,011.87 |