- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $5,495.41 / $10,471.29
| Facility | | $1,548.82 | $5,495.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,737.80 / $2,398.83
| Professional | | $1,584.89 | $1,737.80 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,344.23 / $3,090.30
| Professional | | $2,238.72 | $2,344.23 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $5,495.41 / $12,589.25
| Facility | | $1,445.44 | $5,495.41 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,162.28
| Professional | | $2,570.40 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,905.46 / $2,691.53
| Facility | | $1,548.82 | $1,905.46 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,238.72 / $2,691.53
| Facility | | $1,995.26 | $2,238.72 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,454.71
| Professional | | $933.25 | $1,318.26 | $2,454.71 |