- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,265.80 / $10,471.29
| Facility | | $1,819.70 | $4,265.80 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $2,344.23 / $4,265.80
| Professional | | $724.44 | $2,344.23 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,715.35 / $13,182.57
| Facility | | $2,454.71 | $3,715.35 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $4,265.80
| Professional | | $1,174.90 | $1,174.90 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,248.07 / $12,022.64
| Facility | | $1,905.46 | $5,248.07 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,467.37 / $6,918.31
| Professional | | $1,445.44 | $3,467.37 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,951.21 / $3,467.37
| Facility | | $1,318.26 | $2,951.21 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $3,388.44
| Professional | | $1,230.27 | $1,737.80 | $3,388.44 |