- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,370.32 / $9,549.93
| Facility | | $2,630.27 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,137.96 / $5,248.07
| Professional | | $1,737.80 | $2,137.96 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,677.35 / $9,772.37
| Facility | | $1,995.26 | $4,677.35 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,019.95 / $4,265.80
| Professional | | $1,949.84 | $3,019.95 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,388.44 / $5,370.32
| Professional | | $2,089.30 | $3,388.44 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,290.87 / $6,918.31
| Professional | | $1,995.26 | $2,290.87 | $6,918.31 |
- 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
- $1,905.46 / $2,691.53 / $4,786.30
| Professional | | $1,905.46 | $2,691.53 | $4,786.30 |