- 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
- $1,202.26 / $1,445.44 / $3,467.37
| Professional | | $1,202.26 | $1,445.44 | $3,467.37 |
- 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
- $1,071.52 / $1,202.26 / $3,388.44
| Professional | | $1,071.52 | $1,202.26 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,621.81 / $2,691.53
| Professional | | $1,202.26 | $1,621.81 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,778.28 / $5,128.61
| Facility | | $1,230.27 | $1,778.28 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,513.56 / $15,135.61
| Professional | | $1,174.90 | $1,513.56 | $15,135.61 |
- 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
- $1,148.15 / $1,380.38 / $2,570.40
| Professional | | $1,148.15 | $1,380.38 | $2,570.40 |