- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,388.44 / $8,912.51
| Facility | | $1,621.81 | $3,388.44 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,548.82 / $2,089.30
| Professional | | $1,174.90 | $1,548.82 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,235.94 / $9,332.54
| Facility | | $1,949.84 | $3,235.94 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,148.15 / $2,884.03
| Professional | | $977.24 | $1,148.15 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,235.94 / $8,317.64
| Facility | | $1,258.93 | $3,235.94 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,818.38 / $5,370.32
| Professional | | $2,238.72 | $2,818.38 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,949.84 / $2,344.23
| Facility | | $1,174.90 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $2,344.23
| Professional | | $812.83 | $1,174.90 | $2,344.23 |