- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,402.55 / $6,225.02 / $9,648.60
| Facility | | $4,402.55 | $6,225.02 | $9,648.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.86 / $854.13 / $1,432.09
| Professional | | $759.86 | $854.13 | $1,432.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.06 / $1,176.04 / $1,709.82
| Professional | | $979.06 | $1,176.04 | $1,709.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.21 / $1,266.59 / $1,969.60
| Professional | | $1,027.21 | $1,266.59 | $1,969.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.74 / $1,269.55 / $1,947.56
| Professional | | $985.74 | $1,269.55 | $1,947.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,402.55 / $6,225.02 / $9,648.60
| Facility | | $4,402.55 | $6,225.02 | $9,648.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.86 / $854.13 / $1,658.61
| Professional | | $759.86 | $854.13 | $1,658.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.32 / $1,496.01 / $1,914.27
| Professional | | $1,111.32 | $1,496.01 | $1,914.27 |