- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,019.95 / $8,511.38
| Facility | | $1,778.28 | $3,019.95 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,862.09 / $3,019.95
| Professional | | $1,096.48 | $1,862.09 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $630.96 / $4,786.30
| Professional | | $478.63 | $630.96 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $8,317.64
| Professional | | $6,760.83 | $6,760.83 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,019.95 / $9,120.11
| Facility | | $2,691.53 | $3,019.95 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,454.71 / $4,073.80
| Professional | | $1,096.48 | $2,454.71 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,888.44 / $5,888.44
| Facility | | $5,370.32 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,454.71 / $4,365.16
| Professional | | $1,584.89 | $2,454.71 | $4,365.16 |