- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,398.83 / $6,606.93
| Facility | | $1,819.70 | $2,398.83 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,174.90
| Professional | | $1,071.52 | $1,071.52 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $8,709.64 / $21,379.62
| Facility | | $5,248.07 | $8,709.64 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,235.94 / $3,630.78
| Professional | | $2,754.23 | $3,235.94 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,348.96 / $2,398.83
| Facility | | $1,174.90 | $1,348.96 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $954.99 / $1,479.11
| Professional | | $741.31 | $954.99 | $1,479.11 |