- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,235.94 / $6,456.54
| Facility | | $1,698.24 | $3,235.94 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,412.54 / $1,698.24
| Professional | | $1,148.15 | $1,412.54 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Professional | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,162.28 / $3,981.07
| Facility | | $1,584.89 | $3,162.28 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,737.80 / $2,344.23
| Facility | | $1,380.38 | $1,737.80 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,047.13 / $8,709.64
| Professional | | $724.44 | $1,047.13 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,737.80 / $2,089.30
| Facility | | $724.44 | $1,737.80 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,047.13 / $2,238.72
| Professional | | $724.44 | $1,047.13 | $2,238.72 |