- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,677.35 / $9,772.37
| Facility | | $3,235.94 | $4,677.35 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $3,162.28
| Professional | | $1,778.28 | $2,398.83 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,370.32 / $8,709.64
| Facility | | $3,981.07 | $5,370.32 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,089.30 / $7,079.46
| Professional | | $1,288.25 | $2,089.30 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,235.94 / $12,882.50
| Facility | | $2,089.30 | $3,235.94 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,025.60 / $7,079.46
| Professional | | $4,365.16 | $6,025.60 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,949.84 / $5,623.41
| Professional | | $1,548.82 | $1,949.84 | $5,623.41 |