- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,491.37 / $2,491.37 / $2,491.37
| Facility | | $2,491.37 | $2,491.37 | $2,491.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.34 / $1,734.50 / $2,775.19
| Professional | | $800.34 | $1,734.50 | $2,775.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,462.55 / $2,686.77 / $2,849.83
| Facility | | $2,462.55 | $2,686.77 | $2,849.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,666.83 / $2,666.83 / $2,666.83
| Professional | | $2,666.83 | $2,666.83 | $2,666.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,552.76 / $1,552.76 / $1,552.76
| Facility | | $1,552.76 | $1,552.76 | $1,552.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.51 / $1,133.51 / $4,399.68
| Professional | | $1,133.51 | $1,133.51 | $4,399.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $800.34 / $2,670.24 / $13,558.52
| Facility | | $800.34 | $2,670.24 | $13,558.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.48 / $1,771.08 / $4,232.93
| Professional | | $826.48 | $1,771.08 | $4,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.98 / $1,652.96 / $2,116.46
| Professional | | $1,101.98 | $1,652.96 | $2,116.46 |