- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,011.87 / $9,549.93
| Facility | | $1,412.54 | $5,011.87 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,621.81 / $2,187.76
| Professional | | $1,412.54 | $1,621.81 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,187.76 / $2,818.38
| Professional | | $2,041.74 | $2,187.76 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $5,011.87 / $11,481.54
| Facility | | $1,318.26 | $5,011.87 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,659.59 / $2,570.40
| Facility | | $1,230.27 | $1,659.59 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,454.71
| Facility | | $1,819.70 | $2,041.74 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,230.27 / $2,041.74
| Professional | | $851.14 | $1,230.27 | $2,041.74 |