- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,548.13 / $7,079.46
| Facility | | $1,819.70 | $3,548.13 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,548.82 / $2,290.87
| Professional | | $1,318.26 | $1,548.82 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Professional | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,467.37 / $4,265.80
| Facility | | $1,698.24 | $3,467.37 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,905.46 / $2,570.40
| Facility | | $1,513.56 | $1,905.46 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,148.15 / $9,549.93
| Professional | | $794.33 | $1,148.15 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,905.46 / $2,290.87
| Facility | | $794.33 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,148.15 / $2,454.71
| Professional | | $794.33 | $1,148.15 | $2,454.71 |