- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,466.84 / $5,754.40
| Facility | | $3,890.45 | $4,466.84 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,311.31 / $4,466.84
| Professional | | $2,344.23 | $3,311.31 | $4,466.84 |
- 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
- $2,511.89 / $3,630.78 / $4,897.79
| Professional | | $2,511.89 | $3,630.78 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,162.28 / $8,317.64
| Facility | | $2,454.71 | $3,162.28 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,467.37 / $3,890.45
| Facility | | $1,621.81 | $3,467.37 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $2,344.23
| Professional | | $1,621.81 | $1,621.81 | $2,344.23 |