- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $5,370.32 / $9,549.93
| Facility | | $1,819.70 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,348.96 / $2,691.53
| Professional | | $1,096.48 | $1,348.96 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,365.16 / $9,549.93
| Facility | | $1,513.56 | $4,365.16 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,905.46 / $2,691.53
| Professional | | $1,174.90 | $1,905.46 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,949.84 / $3,235.94
| Professional | | $1,348.96 | $1,949.84 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,412.54 / $3,715.35
| Professional | | $1,174.90 | $1,412.54 | $3,715.35 |
- 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
- $1,202.26 / $1,778.28 / $3,019.95
| Professional | | $1,202.26 | $1,778.28 | $3,019.95 |