- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,365.16 / $6,918.31
| Facility | | $1,819.70 | $4,365.16 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,698.24 / $1,819.70
| Professional | | $1,318.26 | $1,698.24 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,548.13
| Professional | | $2,884.03 | $2,884.03 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,454.71 / $4,677.35
| Facility | | $1,698.24 | $2,454.71 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,454.71 / $5,623.41
| Professional | | $1,698.24 | $2,454.71 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $4,365.16
| Professional | | $3,548.13 | $3,548.13 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Facility | | $8,709.64 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,691.53 / $5,128.61
| Professional | | $1,778.28 | $2,691.53 | $5,128.61 |