- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,235.94 / $9,549.93
| Facility | | $2,570.40 | $3,235.94 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,511.89 / $4,073.80
| Professional | | $2,137.96 | $2,511.89 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $8,511.38
| Facility | | $2,089.30 | $2,089.30 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $4,677.35
| Professional | | $3,890.45 | $3,890.45 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,235.94 / $5,623.41
| Facility | | $2,290.87 | $3,235.94 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $4,265.80
| Professional | | $1,348.96 | $1,348.96 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,235.94 / $3,801.89
| Facility | | $1,348.96 | $3,235.94 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $2,089.30
| Professional | | $1,348.96 | $1,348.96 | $2,089.30 |