- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,630.27 / $8,912.51
| Facility | | $1,258.93 | $2,630.27 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,290.87 / $4,073.80
| Professional | | $1,698.24 | $2,290.87 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,754.23 / $3,548.13
| Professional | | $2,041.74 | $2,754.23 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,890.45 / $19,498.45
| Facility | | $2,187.76 | $3,890.45 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $16,595.87
| Professional | | $1,819.70 | $2,454.71 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $11,748.98 / $21,379.62
| Facility | | $3,235.94 | $11,748.98 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,187.76 / $3,019.95
| Professional | | $1,698.24 | $2,187.76 | $3,019.95 |