- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,041.74 / $7,762.47
| Facility | | $1,949.84 | $2,041.74 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,737.80 / $5,754.40
| Professional | | $1,318.26 | $1,737.80 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,137.96 / $2,630.27
| Professional | | $1,148.15 | $2,137.96 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $1,995.26
| Professional | | $32.36 | $33.11 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,041.74 / $3,630.78
| Facility | | $1,548.82 | $2,041.74 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,041.74 / $2,630.27
| Professional | | $1,148.15 | $2,041.74 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $7,762.47 / $13,803.84
| Facility | | $794.33 | $7,762.47 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,137.96 / $3,162.28
| Professional | | $1,621.81 | $2,137.96 | $3,162.28 |