- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,168.69 / $7,762.47
| Facility | | $3,235.94 | $4,168.69 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,168.69 / $7,413.10
| Professional | | $3,388.44 | $4,168.69 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,466.84 / $14,791.08
| Facility | | $3,235.94 | $4,466.84 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,365.16 / $9,772.37
| Professional | | $4,168.69 | $4,365.16 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $28,840.32
| Facility | | $4,897.79 | $4,897.79 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $10,964.78
| Professional | | $3,630.78 | $3,630.78 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,370.32 / $9,772.37
| Facility | | $3,019.95 | $5,370.32 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,265.80 / $6,025.60
| Professional | | $2,951.21 | $4,265.80 | $6,025.60 |