- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,011.87 / $9,332.54
| Facility | | $3,801.89 | $5,011.87 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,445.44 / $3,630.78
| Professional | | $1,258.93 | $1,445.44 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,513.56 / $2,951.21
| Facility | | $1,174.90 | $1,513.56 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,951.21 / $3,090.30
| Professional | | $2,754.23 | $2,951.21 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,630.78 / $4,570.88
| Professional | | $2,290.87 | $3,630.78 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,258.93 / $8,912.51
| Facility | | $676.08 | $1,258.93 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,148.15 / $5,495.41
| Professional | | $794.33 | $1,148.15 | $5,495.41 |
- 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
- $794.33 / $1,819.70 / $3,801.89
| Facility | | $794.33 | $1,819.70 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,148.15 / $1,905.46
| Professional | | $1,071.52 | $1,148.15 | $1,905.46 |