- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,238.72 / $7,943.28
| Facility | | $1,621.81 | $2,238.72 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,318.26 / $1,949.84
| Professional | | $912.01 | $1,318.26 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,019.95 / $4,786.30
| Facility | | $1,659.59 | $3,019.95 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Professional | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Facility | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,202.26 / $11,748.98
| Facility | | $1,000.00 | $1,202.26 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,548.82 / $1,548.82
| Facility | | $645.65 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $776.25 / $2,137.96
| Professional | | $645.65 | $776.25 | $2,137.96 |