- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $5,370.32 / $10,471.29
| Facility | | $1,548.82 | $5,370.32 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,698.24 / $2,187.76
| Professional | | $1,548.82 | $1,698.24 | $2,187.76 |
- 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
- $2,187.76 / $2,344.23 / $3,090.30
| Professional | | $2,187.76 | $2,344.23 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $5,623.41 / $12,589.25
| Facility | | $1,445.44 | $5,623.41 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,905.46 / $3,801.89
| Facility | | $1,659.59 | $1,905.46 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,187.76 / $2,630.27
| Facility | | $1,995.26 | $2,187.76 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,187.76
| Professional | | $933.25 | $1,318.26 | $2,187.76 |