- 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
- $1,174.90 / $1,819.70 / $2,951.21
| Professional | | $1,174.90 | $1,819.70 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,715.35 / $4,570.88
| Professional | | $3,090.30 | $3,715.35 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,019.95 / $5,128.61
| Professional | | $2,454.71 | $3,019.95 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,398.83 / $5,248.07
| Facility | | $1,737.80 | $2,398.83 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,235.94 / $4,073.80
| Professional | | $1,819.70 | $3,235.94 | $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
- $1,819.70 / $3,311.31 / $4,365.16
| Professional | | $1,819.70 | $3,311.31 | $4,365.16 |