- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,623.41 / $10,471.29
| Facility | | $1,949.84 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $870.96 / $2,089.30
| Professional | | $478.63 | $870.96 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,698.24 / $5,623.41
| Facility | | $489.78 | $1,698.24 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,238.72 / $7,079.46
| Professional | | $1,819.70 | $2,238.72 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,398.83 / $4,677.35
| Facility | | $1,348.96 | $2,398.83 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,137.96 / $2,884.03
| Professional | | $1,659.59 | $2,137.96 | $2,884.03 |