- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $6,606.93 / $12,882.50
| Facility | | $1,905.46 | $6,606.93 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,089.30 / $2,570.40
| Professional | | $1,819.70 | $2,089.30 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,884.03 / $3,801.89
| Professional | | $2,691.53 | $2,884.03 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $6,606.93 / $15,488.17
| Facility | | $1,778.28 | $6,606.93 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,344.23 / $4,677.35
| Facility | | $2,041.74 | $2,344.23 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,691.53 / $3,235.94
| Facility | | $2,454.71 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $2,691.53
| Professional | | $1,148.15 | $1,621.81 | $2,691.53 |