- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $2,570.40
| Facility | | $1,047.13 | $1,047.13 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $1,148.15
| Professional | | $794.33 | $1,071.52 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Professional | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $35,481.34
| Facility | | $4,466.84 | $4,466.84 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,089.30
| Professional | | $870.96 | $1,445.44 | $2,089.30 |