- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $5,623.41 / $10,715.19
| Facility | | $1,584.89 | $5,623.41 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,778.28 / $1,995.26
| Professional | | $1,584.89 | $1,778.28 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,379.62 / $21,379.62 / $21,379.62
| Facility | | $21,379.62 | $21,379.62 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,454.71 / $3,162.28
| Professional | | $2,290.87 | $2,454.71 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $5,754.40 / $12,882.50
| Facility | | $1,479.11 | $5,754.40 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,041.74 / $4,168.69
| Facility | | $1,698.24 | $2,041.74 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,290.87 / $2,754.23
| Facility | | $2,041.74 | $2,290.87 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,380.38 / $2,290.87
| Professional | | $954.99 | $1,380.38 | $2,290.87 |