- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,630.78 / $7,244.36
| Facility | | $1,905.46 | $3,630.78 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,584.89 / $1,949.84
| Professional | | $1,288.25 | $1,584.89 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Professional | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,548.13 / $4,365.16
| Facility | | $1,737.80 | $3,548.13 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,949.84 / $2,630.27
| Facility | | $1,548.82 | $1,949.84 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $9,772.37
| Professional | | $812.83 | $1,174.90 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,949.84 / $2,344.23
| Facility | | $812.83 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $2,511.89
| Professional | | $812.83 | $1,174.90 | $2,511.89 |