- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,467.37 / $6,760.83
| Facility | | $1,202.26 | $3,467.37 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,348.96 / $2,630.27
| Professional | | $1,202.26 | $1,348.96 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,548.82 / $2,238.72
| Professional | | $870.96 | $1,548.82 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,995.26 / $8,709.64
| Facility | | $1,230.27 | $1,995.26 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,445.44 / $9,772.37
| Professional | | $912.01 | $1,445.44 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $5,754.40 / $10,715.19
| Facility | | $1,621.81 | $5,754.40 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,258.93 / $1,819.70
| Professional | | $794.33 | $1,258.93 | $1,819.70 |