- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,819.70 / $8,511.38
| Facility | | $1,737.80 | $1,819.70 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,819.70 / $2,951.21
| Professional | | $1,148.15 | $1,819.70 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,801.89 / $4,466.84
| Professional | | $3,090.30 | $3,801.89 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,019.95 / $5,011.87
| Professional | | $2,398.83 | $3,019.95 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,398.83 / $5,128.61
| Facility | | $1,737.80 | $2,398.83 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,162.28 / $4,073.80
| Professional | | $1,778.28 | $3,162.28 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,235.94 / $4,265.80
| Professional | | $1,778.28 | $3,235.94 | $4,265.80 |