- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,488.34 / $1,658.44 / $10,083.29
| Facility | | $1,488.34 | $1,658.44 | $10,083.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,658.44 / $1,658.44 / $1,700.96
| Professional | | $1,658.44 | $1,658.44 | $1,700.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,126.19 / $2,232.51 / $2,934.16
| Professional | | $2,126.19 | $2,232.51 | $2,934.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,416.79 / $4,311.93 / $12,123.17
| Facility | | $1,416.79 | $4,311.93 | $12,123.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,637.17 / $2,126.19 / $2,275.03
| Facility | | $1,637.17 | $2,126.19 | $2,275.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.00 / $1,169.41 / $1,936.14
| Professional | | $893.00 | $1,169.41 | $1,936.14 |