- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $8,317.64 / $12,302.69
| Facility | | $1,819.70 | $8,317.64 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,995.26 / $2,570.40
| Professional | | $1,819.70 | $1,995.26 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $1,819.70
| Facility | | $1,819.70 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,754.23 / $3,630.78
| Professional | | $2,570.40 | $2,754.23 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $6,309.57 / $14,791.08
| Facility | | $1,659.59 | $6,309.57 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,238.72 / $4,365.16
| Facility | | $1,949.84 | $2,238.72 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,570.40 / $3,090.30
| Facility | | $2,290.87 | $2,570.40 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,548.82 / $2,570.40
| Professional | | $1,071.52 | $1,548.82 | $2,570.40 |