- 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
- $1,621.81 / $1,995.26 / $3,388.44
| Professional | | $1,621.81 | $1,995.26 | $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
- $1,513.56 / $2,754.23 / $3,890.45
| Professional | | $1,513.56 | $2,754.23 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,754.23 / $4,677.35
| Professional | | $1,819.70 | $2,754.23 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,041.74 / $2,754.23
| Professional | | $1,737.80 | $2,041.74 | $2,754.23 |
- 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
- $1,737.80 / $2,630.27 / $4,570.88
| Professional | | $1,737.80 | $2,630.27 | $4,570.88 |