- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,495.41 / $9,549.93
| Facility | | $3,019.95 | $5,495.41 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,454.71 / $5,248.07
| Professional | | $1,949.84 | $2,454.71 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $6,309.57 / $12,302.69
| Facility | | $2,238.72 | $6,309.57 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,388.44 / $4,677.35
| Professional | | $2,187.76 | $3,388.44 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,630.78 / $6,165.95
| Professional | | $1,995.26 | $3,630.78 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,884.03 / $7,079.46
| Professional | | $2,238.72 | $2,884.03 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,235.94 / $7,943.28
| Facility | | $602.56 | $3,235.94 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,884.03 / $5,754.40
| Professional | | $2,187.76 | $2,884.03 | $5,754.40 |