- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,238.72 / $6,606.93
| Facility | | $1,778.28 | $2,238.72 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,659.59 / $2,137.96
| Professional | | $1,479.11 | $1,659.59 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $5,888.44
| Facility | | $1,445.44 | $1,445.44 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,162.28
| Professional | | $2,570.40 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,737.80 / $7,413.10
| Facility | | $1,318.26 | $1,737.80 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $2,238.72
| Professional | | $933.25 | $933.25 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,238.72 / $2,691.53
| Facility | | $794.33 | $2,238.72 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $1,318.26
| Professional | | $933.25 | $933.25 | $1,318.26 |