- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,786.30 / $9,772.37
| Facility | | $2,089.30 | $4,786.30 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,348.96 / $4,073.80
| Professional | | $1,148.15 | $1,348.96 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $5,370.32 / $7,943.28
| Facility | | $1,659.59 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $3,388.44
| Professional | | $1,548.82 | $1,819.70 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,548.82 / $2,570.40
| Professional | | $1,122.02 | $1,548.82 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $9,332.54
| Facility | | $1,230.27 | $1,737.80 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,548.82 / $9,549.93
| Professional | | $1,122.02 | $1,548.82 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $7,244.36 / $10,964.78
| Facility | | $5,248.07 | $7,244.36 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,348.96 / $2,344.23
| Professional | | $1,096.48 | $1,348.96 | $2,344.23 |