- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,606.93 / $9,772.37
| Facility | | $2,398.83 | $6,606.93 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,905.46 / $3,715.35
| Professional | | $1,659.59 | $1,905.46 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $8,511.38 / $13,182.57
| Facility | | $3,890.45 | $8,511.38 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $5,128.61
| Professional | | $1,659.59 | $3,548.13 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $2,754.23 / $4,897.79
| Professional | | $691.83 | $2,754.23 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $3,388.44 / $7,413.10
| Facility | | $446.68 | $3,388.44 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,691.53 / $4,265.80
| Professional | | $1,905.46 | $2,691.53 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $3,388.44 / $7,413.10
| Facility | | $446.68 | $3,388.44 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,754.23 / $5,011.87
| Professional | | $1,819.70 | $2,754.23 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,819.70 / $2,238.72
| Facility | | $1,318.26 | $1,819.70 | $2,238.72 |