- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,370.32 / $9,549.93
| Facility | | $2,511.89 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,862.09 / $3,467.37
| Professional | | $1,513.56 | $1,862.09 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,801.89 / $7,244.36
| Facility | | $1,479.11 | $3,801.89 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,630.27 / $3,630.78
| Professional | | $1,659.59 | $2,630.27 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,754.23 / $4,466.84
| Professional | | $1,905.46 | $2,754.23 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,949.84 / $3,890.45
| Professional | | $1,659.59 | $1,949.84 | $3,890.45 |
- 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
- $1,659.59 / $2,454.71 / $4,168.69
| Professional | | $1,659.59 | $2,454.71 | $4,168.69 |