- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,760.83 / $9,772.37
| Facility | | $2,398.83 | $6,760.83 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,995.26 / $3,715.35
| Professional | | $1,698.24 | $1,995.26 | $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
- $1,698.24 / $3,630.78 / $5,248.07
| Professional | | $1,698.24 | $3,630.78 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $2,884.03 / $5,011.87
| Professional | | $691.83 | $2,884.03 | $5,011.87 |
- 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
- $1,949.84 / $2,818.38 / $4,466.84
| Professional | | $1,949.84 | $2,818.38 | $4,466.84 |
- 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
- $1,862.09 / $2,818.38 / $5,128.61
| Professional | | $1,862.09 | $2,818.38 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,862.09 / $2,290.87
| Facility | | $1,380.38 | $1,862.09 | $2,290.87 |