- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,370.32 / $9,549.93
| Facility | | $1,737.80 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,412.54 / $2,951.21
| Professional | | $1,148.15 | $1,412.54 | $2,951.21 |
- 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
- $1,258.93 / $2,041.74 / $2,818.38
| Professional | | $1,258.93 | $2,041.74 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,187.76 / $3,388.44
| Professional | | $1,348.96 | $2,187.76 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,513.56 / $3,890.45
| Professional | | $1,348.96 | $1,513.56 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $9,549.93 / $23,988.33
| Facility | | $2,398.83 | $9,549.93 | $23,988.33 |
- 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 |