- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $5,248.07 / $12,022.64
| Facility | | $1,548.82 | $5,248.07 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,548.82 / $3,162.28
| Professional | | $1,174.90 | $1,548.82 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $8,709.64 / $16,982.44
| Facility | | $3,162.28 | $8,709.64 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,513.56 / $3,162.28
| Professional | | $1,071.52 | $1,513.56 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,630.78 / $10,232.93
| Facility | | $1,202.26 | $3,630.78 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,862.09 / $4,570.88
| Professional | | $1,122.02 | $1,862.09 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $5,495.41 / $12,589.25
| Facility | | $1,819.70 | $5,495.41 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,412.54 / $2,754.23
| Professional | | $1,047.13 | $1,412.54 | $2,754.23 |