- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,370.32 / $7,413.10
| Facility | | $2,187.76 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $2,951.21
| Professional | | $1,288.25 | $1,698.24 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,162.28 / $6,918.31
| Facility | | $1,230.27 | $3,162.28 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,089.30 / $2,818.38
| Professional | | $1,380.38 | $2,089.30 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,290.87 / $3,548.13
| Professional | | $1,318.26 | $2,290.87 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,659.59 / $3,801.89
| Professional | | $1,288.25 | $1,659.59 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $6,918.31 / $12,022.64
| Facility | | $1,737.80 | $6,918.31 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,949.84 / $3,388.44
| Professional | | $1,445.44 | $1,949.84 | $3,388.44 |