- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,370.32 / $7,943.28
| Facility | | $2,290.87 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,348.96 / $2,570.40
| Professional | | $1,122.02 | $1,348.96 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $3,388.44 / $6,918.31
| Facility | | $1,412.54 | $3,388.44 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,621.81 / $2,344.23
| Professional | | $1,047.13 | $1,621.81 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Facility | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,862.09 / $3,162.28
| Professional | | $1,122.02 | $1,862.09 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,348.96 / $2,884.03
| Professional | | $1,096.48 | $1,348.96 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $6,918.31 / $12,022.64
| Facility | | $1,737.80 | $6,918.31 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,513.56 / $2,951.21
| Professional | | $1,096.48 | $1,513.56 | $2,951.21 |