- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,466.84 / $10,232.93
| Facility | | $2,238.72 | $4,466.84 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,466.84 / $9,772.37
| Professional | | $3,548.13 | $4,466.84 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,073.80 / $5,888.44
| Facility | | $3,388.44 | $4,073.80 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,370.32 / $7,079.46
| Professional | | $4,073.80 | $5,370.32 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,466.84 / $6,309.57
| Professional | | $3,388.44 | $4,466.84 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,570.40 / $6,606.93
| Facility | | $1,071.52 | $2,570.40 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,897.79 / $6,918.31
| Professional | | $3,801.89 | $4,897.79 | $6,918.31 |