- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,819.70 / $8,511.38
| Facility | | $1,737.80 | $1,819.70 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,819.70 / $2,691.53
| Professional | | $1,621.81 | $1,819.70 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,265.80 / $5,011.87
| Professional | | $3,388.44 | $4,265.80 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,311.31 / $5,888.44
| Professional | | $2,454.71 | $3,311.31 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,691.53 / $5,495.41
| Facility | | $1,819.70 | $2,691.53 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,311.31 / $3,890.45
| Professional | | $1,778.28 | $3,311.31 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,311.31 / $4,365.16
| Professional | | $1,778.28 | $3,311.31 | $4,365.16 |