- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,137.96 / $4,897.79
| Facility | | $1,348.96 | $2,137.96 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,659.59 / $3,311.31
| Professional | | $1,258.93 | $1,659.59 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,623.41 / $12,302.69
| Facility | | $2,290.87 | $5,623.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,995.26 / $3,630.78
| Professional | | $1,348.96 | $1,995.26 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $2,570.40 / $11,481.54
| Facility | | $676.08 | $2,570.40 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,290.87 / $4,466.84
| Professional | | $1,445.44 | $2,290.87 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,918.31 / $15,488.17
| Facility | | $2,398.83 | $6,918.31 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,905.46 / $3,388.44
| Professional | | $1,258.93 | $1,905.46 | $3,388.44 |