- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,715.35 / $9,549.93
| Facility | | $1,230.27 | $3,715.35 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,230.27 / $2,630.27
| Professional | | $1,023.29 | $1,230.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,888.44 / $13,489.63
| Facility | | $2,290.87 | $5,888.44 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,412.54 / $2,884.03
| Professional | | $977.24 | $1,412.54 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,290.87 / $8,128.31
| Facility | | $1,202.26 | $2,290.87 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,698.24 / $3,630.78
| Professional | | $1,122.02 | $1,698.24 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $12,302.69
| Facility | | $1,949.84 | $5,495.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,380.38 / $2,570.40
| Professional | | $954.99 | $1,380.38 | $2,570.40 |