- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,370.32 / $9,549.93
| Facility | | $2,511.89 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,398.83 / $4,897.79
| Professional | | $1,995.26 | $2,398.83 | $4,897.79 |
- 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
- $2,041.74 / $3,162.28 / $4,677.35
| Professional | | $2,041.74 | $3,162.28 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,801.89 / $5,754.40
| Professional | | $2,041.74 | $3,801.89 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,570.40 / $6,456.54
| Professional | | $2,290.87 | $2,570.40 | $6,456.54 |
- 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
- $1,995.26 / $2,691.53 / $5,370.32
| Professional | | $1,995.26 | $2,691.53 | $5,370.32 |