- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.65 / $2,864.29 / $7,753.41
| Facility | | $1,770.65 | $2,864.29 | $7,753.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.23 / $1,612.86 / $1,651.73
| Professional | | $1,292.23 | $1,612.86 | $1,651.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $494.98 / $1,879.78 / $2,977.83
| Facility | | $494.98 | $1,879.78 | $2,977.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $939.23 / $1,366.15 / $6,617.30
| Professional | | $939.23 | $1,366.15 | $6,617.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.19 / $3,157.73 / $5,683.91
| Facility | | $1,285.19 | $3,157.73 | $5,683.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,301.95 / $1,943.21 / $3,577.10
| Facility | | $1,301.95 | $1,943.21 | $3,577.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.15 / $816.15 / $9,677.19
| Professional | | $816.15 | $816.15 | $9,677.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.15 / $816.15 / $1,165.93
| Professional | | $816.15 | $816.15 | $1,165.93 |