- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,467.37 / $4,897.79
| Facility | | $1,380.38 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,479.11 / $2,290.87
| Professional | | $1,258.93 | $1,479.11 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $19,054.61 / $27,542.29
| Facility | | $9,549.93 | $19,054.61 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,659.59 / $2,691.53
| Professional | | $1,230.27 | $1,659.59 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,348.96 / $1,513.56
| Facility | | $1,288.25 | $1,348.96 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $2,951.21
| Professional | | $1,288.25 | $1,698.24 | $2,951.21 |
- 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
- $1,202.26 / $1,548.82 / $2,511.89
| Professional | | $1,202.26 | $1,548.82 | $2,511.89 |