- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $6,025.60 / $12,022.64
| Facility | | $1,548.82 | $6,025.60 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,548.82 / $2,041.74
| Professional | | $1,318.26 | $1,548.82 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,621.81 / $8,912.51
| Facility | | $1,202.26 | $1,621.81 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,162.28 / $10,715.19
| Professional | | $2,570.40 | $3,162.28 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,995.26
| Professional | | $1,318.26 | $1,318.26 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,318.26 / $2,238.72
| Facility | | $851.14 | $1,318.26 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $933.25 / $2,238.72
| Professional | | $776.25 | $933.25 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $2,238.72
| Professional | | $1,318.26 | $1,318.26 | $2,238.72 |