- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,623.41 / $9,549.93
| Facility | | $4,265.80 | $5,623.41 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,630.78 / $6,165.95
| Professional | | $2,951.21 | $3,630.78 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $5,888.44 / $12,022.64
| Facility | | $2,238.72 | $5,888.44 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,365.16 / $6,918.31
| Professional | | $2,754.23 | $4,365.16 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,128.61 / $9,120.11
| Professional | | $3,235.94 | $5,128.61 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,890.45 / $7,079.46
| Professional | | $3,388.44 | $3,890.45 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,235.94 / $8,128.31
| Facility | | $1,047.13 | $3,235.94 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,265.80 / $8,128.31
| Professional | | $2,951.21 | $4,265.80 | $8,128.31 |