- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,677.35 / $8,912.51
| Facility | | $1,318.26 | $4,677.35 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,513.56 / $1,819.70
| Professional | | $1,318.26 | $1,513.56 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,041.74 / $2,691.53
| Professional | | $1,905.46 | $2,041.74 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,786.30 / $10,715.19
| Facility | | $1,230.27 | $4,786.30 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,698.24 / $3,467.37
| Facility | | $1,412.54 | $1,698.24 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,905.46 / $2,290.87
| Facility | | $1,698.24 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,148.15 / $1,905.46
| Professional | | $794.33 | $1,148.15 | $1,905.46 |