- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,162.28 / $9,549.93
| Facility | | $2,344.23 | $3,162.28 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,344.23 / $3,981.07
| Professional | | $2,187.76 | $2,344.23 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $8,511.38
| Facility | | $2,041.74 | $2,041.74 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $4,570.88
| Professional | | $3,890.45 | $3,890.45 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,162.28 / $5,495.41
| Facility | | $2,344.23 | $3,162.28 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $11,748.98
| Professional | | $1,318.26 | $1,318.26 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,162.28 / $3,801.89
| Facility | | $1,318.26 | $3,162.28 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $2,089.30
| Professional | | $1,318.26 | $1,318.26 | $2,089.30 |