- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,019.95 / $7,943.28
| Facility | | $1,445.44 | $3,019.95 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,380.38 / $1,698.24
| Professional | | $1,047.13 | $1,380.38 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,951.21 / $8,317.64
| Facility | | $1,698.24 | $2,951.21 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $870.96 / $2,187.76
| Professional | | $851.14 | $870.96 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,884.03 / $7,413.10
| Facility | | $1,122.02 | $2,884.03 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,511.89 / $4,786.30
| Professional | | $2,041.74 | $2,511.89 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,737.80 / $2,089.30
| Facility | | $1,047.13 | $1,737.80 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,047.13 / $2,089.30
| Professional | | $724.44 | $1,047.13 | $2,089.30 |