- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,495.41 / $9,549.93
| Facility | | $4,168.69 | $5,495.41 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,137.96 / $5,623.41
| Professional | | $1,659.59 | $2,137.96 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,168.69 / $12,022.64
| Facility | | $3,715.35 | $4,168.69 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,801.89 / $5,495.41
| Professional | | $1,819.70 | $3,801.89 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $2,290.87
| Facility | | $1,659.59 | $1,659.59 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,235.94 / $5,248.07
| Professional | | $1,995.26 | $3,235.94 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,570.40 / $3,890.45
| Professional | | $1,995.26 | $2,570.40 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,466.84 / $9,332.54
| Facility | | $1,819.70 | $4,466.84 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,884.03 / $5,495.41
| Professional | | $1,479.11 | $2,884.03 | $5,495.41 |