- 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
- $1,380.38 / $1,659.59 / $3,715.35
| Professional | | $1,380.38 | $1,659.59 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $4,365.16 / $7,943.28
| Facility | | $1,659.59 | $4,365.16 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,995.26 / $3,162.28
| Professional | | $1,548.82 | $1,995.26 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,995.26 / $3,235.94
| Professional | | $1,318.26 | $1,995.26 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,778.28 / $4,265.80
| Facility | | $1,380.38 | $1,778.28 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,089.30 / $10,964.78
| Professional | | $1,445.44 | $2,089.30 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,089.30 / $5,248.07
| Facility | | $831.76 | $2,089.30 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,819.70 / $3,090.30
| Professional | | $1,412.54 | $1,819.70 | $3,090.30 |