- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,698.24 / $8,511.38
| Facility | | $1,621.81 | $1,698.24 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,621.81 / $2,511.89
| Professional | | $1,548.82 | $1,621.81 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,981.07 / $4,677.35
| Professional | | $3,235.94 | $3,981.07 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,162.28 / $5,495.41
| Professional | | $2,290.87 | $3,162.28 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $5,128.61
| Facility | | $1,698.24 | $2,511.89 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,090.30 / $3,630.78
| Professional | | $1,479.11 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $8,912.51 / $8,912.51
| Facility | | $7,943.28 | $8,912.51 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,090.30 / $4,073.80
| Professional | | $1,479.11 | $3,090.30 | $4,073.80 |