- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,623.41 / $9,549.93
| Facility | | $4,168.69 | $5,623.41 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,137.96 / $3,630.78
| Professional | | $1,737.80 | $2,137.96 | $3,630.78 |
- 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
- $1,862.09 / $2,951.21 / $4,365.16
| Professional | | $1,862.09 | $2,951.21 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $4,897.79
| Professional | | $2,089.30 | $3,019.95 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,238.72 / $12,882.50
| Professional | | $1,862.09 | $2,238.72 | $12,882.50 |
- 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 / $2,818.38 / $4,786.30
| Professional | | $1,905.46 | $2,818.38 | $4,786.30 |