- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,819.70 / $2,691.53
| Facility | | $1,348.96 | $1,819.70 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,548.82 / $2,238.72
| Professional | | $1,380.38 | $1,548.82 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $4,168.69
| Facility | | $3,019.95 | $3,019.95 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $2,137.96
| Professional | | $1,621.81 | $1,621.81 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,041.74 / $2,570.40
| Professional | | $1,288.25 | $2,041.74 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,445.44 / $5,248.07
| Facility | | $588.84 | $1,445.44 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,698.24 / $2,754.23
| Professional | | $1,318.26 | $1,698.24 | $2,754.23 |