- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,370.32 / $9,549.93
| Facility | | $3,019.95 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,238.72 / $4,466.84
| Professional | | $1,819.70 | $2,238.72 | $4,466.84 |
- 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
- $1,949.84 / $3,162.28 / $4,365.16
| Professional | | $1,949.84 | $3,162.28 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,162.28 / $5,370.32
| Professional | | $2,187.76 | $3,162.28 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,344.23 / $6,309.57
| Professional | | $1,949.84 | $2,344.23 | $6,309.57 |
- 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 / $2,884.03 / $5,011.87
| Professional | | $1,995.26 | $2,884.03 | $5,011.87 |