- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,191.77 / $3,729.83 / $5,721.66
| Facility | | $3,191.77 | $3,729.83 | $5,721.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,945.62 / $2,549.77 / $8,288.62
| Professional | | $1,945.62 | $2,549.77 | $8,288.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,519.31 / $1,738.35 / $2,519.05
| Facility | | $1,519.31 | $1,738.35 | $2,519.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,519.31 / $1,738.35 / $2,519.05
| Facility | | $1,519.31 | $1,738.35 | $2,519.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,041.00 / $8,942.37 / $8,942.37
| Professional | | $8,041.00 | $8,942.37 | $8,942.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,519.31 / $1,738.35 / $2,519.05
| Facility | | $1,519.31 | $1,738.35 | $2,519.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,060.32 / $5,276.72 / $7,841.85
| Facility | | $3,060.32 | $5,276.72 | $7,841.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.32 / $8,041.00 / $8,942.37
| Professional | | $3,060.32 | $8,041.00 | $8,942.37 |