- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,467.37 / $6,760.83
| Facility | | $1,202.26 | $3,467.37 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,621.81 / $2,691.53
| Professional | | $1,288.25 | $1,621.81 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,905.46 / $2,290.87
| Professional | | $1,445.44 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,073.80 / $10,715.19
| Facility | | $1,445.44 | $4,073.80 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $11,481.54
| Professional | | $1,288.25 | $1,698.24 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $5,754.40 / $10,715.19
| Facility | | $1,621.81 | $5,754.40 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,548.82 / $2,187.76
| Professional | | $1,202.26 | $1,548.82 | $2,187.76 |