- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,284.53 / $4,289.43 / $6,628.03
| Facility | | $2,284.53 | $4,289.43 | $6,628.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.85 / $1,805.95 / $2,221.11
| Professional | | $1,556.85 | $1,805.95 | $2,221.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,594.75 / $2,594.75 / $2,594.75
| Professional | | $2,594.75 | $2,594.75 | $2,594.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,835.01 / $3,400.16 / $4,202.97
| Facility | | $1,835.01 | $3,400.16 | $4,202.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,385.08 / $2,408.92 / $3,029.05
| Professional | | $2,385.08 | $2,408.92 | $3,029.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,390.79 / $1,805.95 / $3,611.89
| Facility | | $1,390.79 | $1,805.95 | $3,611.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.84 / $1,245.48 / $3,528.86
| Professional | | $871.84 | $1,245.48 | $3,528.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.84 / $1,245.48 / $3,528.86
| Professional | | $871.84 | $1,245.48 | $3,528.86 |