- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,890.45 / $7,943.28
| Facility | | $2,041.74 | $3,890.45 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,862.09 / $3,162.28
| Professional | | $1,230.27 | $1,862.09 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,318.26 / $1,995.26
| Facility | | $416.87 | $1,318.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $691.83 / $1,949.84
| Professional | | $616.60 | $691.83 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,754.23 / $5,128.61
| Facility | | $1,348.96 | $2,754.23 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,238.72 / $4,365.16
| Professional | | $1,698.24 | $2,238.72 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,162.28 / $5,370.32
| Facility | | $2,238.72 | $3,162.28 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,089.30 / $3,548.13
| Professional | | $1,659.59 | $2,089.30 | $3,548.13 |