- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $6,456.54 / $10,232.93
| Facility | | $1,348.96 | $6,456.54 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,348.96 / $3,388.44
| Professional | | $1,174.90 | $1,348.96 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,019.95 / $3,548.13
| Professional | | $2,454.71 | $3,019.95 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,630.27 / $4,265.80
| Professional | | $1,445.44 | $2,630.27 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,698.24 / $3,981.07
| Facility | | $1,348.96 | $1,698.24 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,344.23 / $10,232.93
| Professional | | $1,412.54 | $2,344.23 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,128.61 / $6,309.57
| Facility | | $4,677.35 | $5,128.61 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,398.83 / $3,235.94
| Professional | | $1,412.54 | $2,398.83 | $3,235.94 |