- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,265.80 / $5,623.41
| Facility | | $3,715.35 | $4,265.80 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,235.94 / $4,570.88
| Professional | | $1,737.80 | $3,235.94 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $891.25
| Facility | | $549.54 | $660.69 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,454.71 / $2,818.38
| Professional | | $1,778.28 | $2,454.71 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,019.95 / $8,128.31
| Facility | | $1,905.46 | $3,019.95 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,778.28 / $4,466.84
| Professional | | $1,621.81 | $1,778.28 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,388.44 / $3,715.35
| Facility | | $1,230.27 | $3,388.44 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $2,238.72
| Professional | | $1,230.27 | $1,584.89 | $2,238.72 |