- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,691.57 / $3,176.10 / $4,907.71
| Facility | | $1,691.57 | $3,176.10 | $4,907.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.77 / $1,337.21 / $1,537.02
| Professional | | $1,152.77 | $1,337.21 | $1,537.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,921.28 / $1,921.28 / $1,921.28
| Professional | | $1,921.28 | $1,921.28 | $1,921.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,358.72 / $2,517.63 / $3,485.43
| Facility | | $1,358.72 | $2,517.63 | $3,485.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,229.61 / $1,537.02 / $2,067.77
| Facility | | $1,229.61 | $1,537.02 | $2,067.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.54 / $922.21 / $7,654.36
| Professional | | $645.54 | $922.21 | $7,654.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,537.02 / $1,537.02 / $1,921.28
| Facility | | $1,537.02 | $1,537.02 | $1,921.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.54 / $922.21 / $2,305.53
| Professional | | $645.54 | $922.21 | $2,305.53 |