- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,570.88 / $8,511.38
| Facility | | $2,290.87 | $4,570.88 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,348.96 / $2,398.83
| Professional | | $1,071.52 | $1,348.96 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $14,125.38 / $16,595.87
| Facility | | $6,606.93 | $14,125.38 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,041.74 / $2,511.89
| Professional | | $1,096.48 | $2,041.74 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,778.28 / $3,090.30
| Professional | | $1,348.96 | $1,778.28 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $2,187.76
| Professional | | $1,659.59 | $1,659.59 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $4,570.88 / $9,332.54
| Facility | | $1,905.46 | $4,570.88 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,513.56 / $3,467.37
| Professional | | $1,071.52 | $1,513.56 | $3,467.37 |