- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $5,888.44 / $10,232.93
| Facility | | $2,041.74 | $5,888.44 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $2,041.74
| Professional | | $1,778.28 | $1,778.28 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,398.83 / $2,511.89
| Facility | | $1,949.84 | $2,398.83 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Professional | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,090.30 / $5,754.40
| Facility | | $2,398.83 | $3,090.30 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,238.72 / $2,238.72
| Professional | | $1,778.28 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,737.80 / $2,137.96
| Professional | | $1,548.82 | $1,737.80 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,949.84
| Professional | | $1,778.28 | $1,778.28 | $1,949.84 |