- 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
- $1,148.15 / $1,445.44 / $2,951.21
| Professional | | $1,148.15 | $1,445.44 | $2,951.21 |
- 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
- $1,096.48 / $1,862.09 / $2,754.23
| Professional | | $1,096.48 | $1,862.09 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,995.26 / $3,235.94
| Professional | | $1,148.15 | $1,995.26 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,380.38 / $2,951.21
| Professional | | $1,148.15 | $1,380.38 | $2,951.21 |
- 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
- $1,202.26 / $1,621.81 / $3,090.30
| Professional | | $1,202.26 | $1,621.81 | $3,090.30 |