- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,692.83 / $2,574.65 / $5,875.61
| Facility | | $1,692.83 | $2,574.65 | $5,875.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.56 / $1,692.83 / $1,802.26
| Professional | | $1,364.56 | $1,692.83 | $1,802.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,018.26 / $5,097.81 / $6,489.60
| Facility | | $3,018.26 | $5,097.81 | $6,489.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,313.07 / $3,994.31 / $13,491.47
| Professional | | $1,313.07 | $3,994.31 | $13,491.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,673.52 / $8,281.03 / $14,777.63
| Facility | | $1,673.52 | $8,281.03 | $14,777.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,802.26 / $4,048.64 / $6,359.39
| Professional | | $1,802.26 | $4,048.64 | $6,359.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,184.33 / $1,544.79 / $4,560.99
| Professional | | $1,184.33 | $1,544.79 | $4,560.99 |