- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,467.37 / $4,897.79
| Facility | | $1,584.89 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,778.28 / $2,754.23
| Professional | | $1,479.11 | $1,778.28 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $19,054.61 / $26,302.68
| Facility | | $9,549.93 | $19,054.61 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,995.26 / $3,162.28
| Professional | | $1,445.44 | $1,995.26 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,621.81 / $1,819.70
| Facility | | $1,548.82 | $1,621.81 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,041.74 / $3,548.13
| Professional | | $1,548.82 | $2,041.74 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,862.09 / $2,951.21
| Professional | | $1,445.44 | $1,862.09 | $2,951.21 |