- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,467.37 / $6,760.83
| Facility | | $1,122.02 | $3,467.37 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,258.93 / $2,570.40
| Professional | | $1,122.02 | $1,258.93 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,659.59 / $2,137.96
| Professional | | $1,318.26 | $1,659.59 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,187.76 / $10,232.93
| Facility | | $1,174.90 | $2,187.76 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,445.44 / $9,332.54
| Professional | | $1,071.52 | $1,445.44 | $9,332.54 |
- 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
- $1,023.29 / $1,288.25 / $1,737.80
| Professional | | $1,023.29 | $1,288.25 | $1,737.80 |