- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,630.27 / $8,912.51
| Facility | | $1,258.93 | $2,630.27 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,089.30
| Professional | | $1,096.48 | $1,445.44 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,819.70 / $2,041.74
| Professional | | $1,318.26 | $1,819.70 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,162.28 / $7,943.28
| Facility | | $1,096.48 | $3,162.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $9,120.11
| Professional | | $1,096.48 | $1,445.44 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,265.80 / $8,128.31
| Facility | | $1,230.27 | $4,265.80 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,318.26 / $2,089.30
| Professional | | $1,047.13 | $1,318.26 | $2,089.30 |