- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,890.45 / $7,943.28
| Facility | | $2,041.74 | $3,890.45 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,584.89 / $4,365.16
| Professional | | $1,348.96 | $1,584.89 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $5,370.32 / $7,943.28
| Facility | | $1,659.59 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,412.54 / $4,365.16
| Professional | | $1,348.96 | $1,412.54 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,659.59 / $2,290.87
| Professional | | $1,348.96 | $1,659.59 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,089.30 / $5,128.61
| Facility | | $1,412.54 | $2,089.30 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,659.59 / $9,772.37
| Professional | | $1,288.25 | $1,659.59 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,290.87 / $5,495.41
| Facility | | $1,348.96 | $2,290.87 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,513.56 / $2,398.83
| Professional | | $1,288.25 | $1,513.56 | $2,398.83 |