- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,370.32 / $9,549.93
| Facility | | $2,570.40 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,949.84 / $3,388.44
| Professional | | $1,548.82 | $1,949.84 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,365.16 / $9,549.93
| Facility | | $1,513.56 | $4,365.16 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,884.03 / $3,801.89
| Professional | | $1,698.24 | $2,884.03 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,884.03 / $4,570.88
| Professional | | $1,949.84 | $2,884.03 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,995.26 / $4,365.16
| Professional | | $1,698.24 | $1,995.26 | $4,365.16 |
- 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
- $1,698.24 / $2,570.40 / $4,265.80
| Professional | | $1,698.24 | $2,570.40 | $4,265.80 |