- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,467.37 / $6,918.31
| Facility | | $1,819.70 | $3,467.37 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,513.56 / $1,862.09
| Professional | | $1,230.27 | $1,513.56 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Professional | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,388.44 / $3,801.89
| Facility | | $1,698.24 | $3,388.44 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,995.26 / $2,511.89
| Facility | | $1,513.56 | $1,995.26 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,122.02 / $9,332.54
| Professional | | $776.25 | $1,122.02 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,862.09 / $2,818.38
| Facility | | $776.25 | $1,862.09 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,122.02 / $2,398.83
| Professional | | $776.25 | $1,122.02 | $2,398.83 |