- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,467.37 / $12,302.69
| Facility | | $2,818.38 | $3,467.37 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,388.44 / $3,981.07
| Professional | | $3,235.94 | $3,388.44 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,073.80 / $8,128.31
| Facility | | $2,398.83 | $4,073.80 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,467.37 / $4,168.69
| Professional | | $1,258.93 | $3,467.37 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,548.13 / $3,548.13
| Facility | | $1,737.80 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,584.89 / $4,073.80
| Facility | | $1,288.25 | $1,584.89 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,467.37 / $4,168.69
| Professional | | $3,388.44 | $3,467.37 | $4,168.69 |