- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,958.85 / $2,448.56 / $5,876.54
| Facility | | $1,958.85 | $2,448.56 | $5,876.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.42 / $1,836.42 / $2,619.96
| Professional | | $1,836.42 | $1,836.42 | $2,619.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.11 / $295.77 / $428.45
| Facility | | $218.11 | $295.77 | $428.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,591.56 / $1,591.56 / $2,148.61
| Facility | | $1,591.56 | $1,591.56 | $2,148.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,982.60 / $2,982.60 / $3,573.49
| Professional | | $2,982.60 | $2,982.60 | $3,573.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,836.42 / $2,448.56 / $4,113.58
| Facility | | $1,836.42 | $2,448.56 | $4,113.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.40 / $1,028.40 / $9,194.91
| Professional | | $1,028.40 | $1,028.40 | $9,194.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.40 / $1,028.40 / $2,448.56
| Professional | | $1,028.40 | $1,028.40 | $2,448.56 |