- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,570.88 / $11,481.54
| Facility | | $1,513.56 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,621.81 / $3,467.37
| Professional | | $1,288.25 | $1,621.81 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $8,511.38 / $16,982.44
| Facility | | $2,187.76 | $8,511.38 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,819.70 / $3,548.13
| Professional | | $1,202.26 | $1,819.70 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $4,168.69 / $16,595.87
| Facility | | $1,288.25 | $4,168.69 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,238.72 / $4,786.30
| Professional | | $1,380.38 | $2,238.72 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,981.07 / $10,471.29
| Facility | | $1,288.25 | $3,981.07 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,778.28 / $3,388.44
| Professional | | $1,258.93 | $1,778.28 | $3,388.44 |