- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $9,549.93
| Facility | | $1,995.26 | $2,691.53 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,621.81 / $2,344.23
| Professional | | $1,122.02 | $1,621.81 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,630.78 / $5,888.44
| Facility | | $2,041.74 | $3,630.78 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Facility | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,659.59 / $1,862.09
| Facility | | $676.08 | $1,659.59 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $933.25 / $2,630.27
| Professional | | $776.25 | $933.25 | $2,630.27 |