- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,498.44 / $2,279.00 / $8,761.84
| Facility | | $1,498.44 | $2,279.00 | $8,761.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.86 / $1,498.44 / $1,595.30
| Professional | | $1,207.86 | $1,498.44 | $1,595.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $865.28 / $3,344.43 / $5,640.53
| Facility | | $865.28 | $3,344.43 | $5,640.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.29 / $1,800.41 / $4,364.37
| Professional | | $1,162.29 | $1,800.41 | $4,364.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,405.70 / $7,330.14 / $13,080.54
| Facility | | $3,405.70 | $7,330.14 | $13,080.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,595.30 / $3,583.73 / $5,629.13
| Professional | | $1,595.30 | $3,583.73 | $5,629.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,048.33 / $1,367.40 / $3,999.42
| Professional | | $1,048.33 | $1,367.40 | $3,999.42 |