- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,457.46 / $4,754.18 / $9,411.65
| Facility | | $4,457.46 | $4,754.18 | $9,411.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.50 / $1,352.06 / $1,709.02
| Professional | | $1,164.50 | $1,352.06 | $1,709.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,387.93 / $1,796.14 / $2,528.38
| Professional | | $1,387.93 | $1,796.14 | $2,528.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.50 / $2,049.34 / $2,906.27
| Professional | | $1,345.50 | $2,049.34 | $2,906.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,651.27 / $1,910.52 / $2,930.84
| Professional | | $1,651.27 | $1,910.52 | $2,930.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,457.46 / $4,754.18 / $9,411.65
| Facility | | $4,457.46 | $4,754.18 | $9,411.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.50 / $1,437.74 / $1,709.02
| Professional | | $1,164.50 | $1,437.74 | $1,709.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.59 / $1,888.44 / $2,667.14
| Professional | | $1,283.59 | $1,888.44 | $2,667.14 |