- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,890.45 / $7,762.47
| Facility | | $1,318.26 | $3,890.45 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,288.25 / $1,995.26
| Professional | | $1,096.48 | $1,288.25 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,412.54 / $1,548.82
| Professional | | $1,122.02 | $1,412.54 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,412.54 / $1,621.81
| Professional | | $1,148.15 | $1,412.54 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,073.80 / $10,964.78
| Facility | | $1,230.27 | $4,073.80 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,318.26 / $8,709.64
| Professional | | $1,000.00 | $1,318.26 | $8,709.64 |
- 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
- $933.25 / $1,174.90 / $1,862.09
| Professional | | $933.25 | $1,174.90 | $1,862.09 |