- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,677.35 / $8,511.38
| Facility | | $2,187.76 | $4,677.35 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,862.09 / $2,187.76
| Professional | | $1,584.89 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Professional | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $4,168.69 / $5,128.61
| Facility | | $2,041.74 | $4,168.69 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,290.87 / $3,090.30
| Facility | | $1,819.70 | $2,290.87 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,380.38 / $11,220.18
| Professional | | $954.99 | $1,380.38 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $2,290.87 / $2,754.23
| Facility | | $954.99 | $2,290.87 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,380.38 / $2,951.21
| Professional | | $954.99 | $1,380.38 | $2,951.21 |