- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,786.30 / $9,332.54
| Facility | | $1,380.38 | $4,786.30 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,548.82 / $2,137.96
| Professional | | $1,380.38 | $1,548.82 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,089.30 / $2,754.23
| Professional | | $1,949.84 | $2,089.30 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $4,786.30 / $11,220.18
| Facility | | $1,258.93 | $4,786.30 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,621.81 / $2,630.27
| Facility | | $1,288.25 | $1,621.81 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,949.84 / $2,344.23
| Facility | | $1,737.80 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $1,949.84
| Professional | | $812.83 | $1,174.90 | $1,949.84 |