- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,370.32 / $9,549.93
| Facility | | $1,698.24 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,445.44 / $2,884.03
| Professional | | $1,174.90 | $1,445.44 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,677.35 / $9,772.37
| Facility | | $1,995.26 | $4,677.35 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,995.26 / $2,818.38
| Professional | | $1,230.27 | $1,995.26 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,238.72 / $3,388.44
| Professional | | $1,380.38 | $2,238.72 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,548.82 / $3,388.44
| Professional | | $1,380.38 | $1,548.82 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,235.94 / $8,128.31
| Facility | | $1,047.13 | $3,235.94 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $3,162.28
| Professional | | $1,230.27 | $1,737.80 | $3,162.28 |