- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,664.35 / $3,079.05 / $6,235.75
| Facility | | $1,664.35 | $3,079.05 | $6,235.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,664.35 / $1,730.92 / $1,881.82
| Professional | | $1,664.35 | $1,730.92 | $1,881.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.95 / $1,442.43 / $3,550.61
| Professional | | $1,153.95 | $1,442.43 | $3,550.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,486.03 / $4,781.51 / $6,346.69
| Facility | | $1,486.03 | $4,781.51 | $6,346.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $2,704.74 / $3,380.93
| Professional | | $2,549.86 | $2,704.74 | $3,380.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,861.29 / $10,540.87 / $10,540.87
| Facility | | $3,861.29 | $10,540.87 | $10,540.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $1,331.48 / $2,219.13
| Professional | | $932.03 | $1,331.48 | $2,219.13 |