- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,778.28 / $8,511.38
| Facility | | $1,659.59 | $1,778.28 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,659.59 / $2,630.27
| Professional | | $1,348.96 | $1,659.59 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,801.89 / $4,570.88
| Professional | | $3,090.30 | $3,801.89 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,311.31 / $5,370.32
| Professional | | $2,290.87 | $3,311.31 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,454.71 / $5,248.07
| Facility | | $1,778.28 | $2,454.71 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,162.28 / $3,801.89
| Professional | | $1,737.80 | $3,162.28 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $8,912.51 / $8,912.51
| Facility | | $7,943.28 | $8,912.51 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,162.28 / $4,365.16
| Professional | | $1,737.80 | $3,162.28 | $4,365.16 |