- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,162.28 / $8,128.31
| Facility | | $1,479.11 | $3,162.28 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,412.54 / $1,737.80
| Professional | | $1,148.15 | $1,412.54 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,311.31 / $8,912.51
| Facility | | $1,737.80 | $3,311.31 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,445.44 / $2,818.38
| Professional | | $1,230.27 | $1,445.44 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,162.28 / $7,943.28
| Facility | | $1,202.26 | $3,162.28 | $7,943.28 |
- 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
- $1,047.13 / $1,949.84 / $2,344.23
| Facility | | $1,047.13 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $2,137.96
| Professional | | $741.31 | $1,047.13 | $2,137.96 |