- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $5,248.07 / $12,589.25
| Facility | | $1,584.89 | $5,248.07 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,621.81 / $3,467.37
| Professional | | $1,258.93 | $1,621.81 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $8,709.64 / $16,982.44
| Facility | | $3,090.30 | $8,709.64 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,621.81 / $3,162.28
| Professional | | $1,122.02 | $1,621.81 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,168.69 / $12,022.64
| Facility | | $1,548.82 | $4,168.69 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,949.84 / $4,570.88
| Professional | | $1,148.15 | $1,949.84 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $5,495.41 / $12,589.25
| Facility | | $1,819.70 | $5,495.41 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $2,884.03
| Professional | | $1,122.02 | $1,513.56 | $2,884.03 |