- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,470.44 / $2,760.90 / $4,266.14
| Facility | | $1,470.44 | $2,760.90 | $4,266.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.07 / $1,162.40 / $1,429.62
| Professional | | $1,002.07 | $1,162.40 | $1,429.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,670.11 / $1,670.11 / $1,670.11
| Professional | | $1,670.11 | $1,670.11 | $1,670.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.10 / $2,188.52 / $3,029.77
| Facility | | $1,181.10 | $2,188.52 | $3,029.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,068.86 / $1,336.09 / $1,797.46
| Facility | | $1,068.86 | $1,336.09 | $1,797.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.16 / $801.65 / $6,653.73
| Professional | | $561.16 | $801.65 | $6,653.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $801.65 / $801.65 / $1,336.09
| Facility | | $801.65 | $801.65 | $1,336.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.16 / $801.65 / $2,004.14
| Professional | | $561.16 | $801.65 | $2,004.14 |