- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,630.78 / $12,882.50
| Facility | | $2,691.53 | $3,630.78 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,187.76 / $3,162.28
| Professional | | $1,513.56 | $2,187.76 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,897.79 / $7,762.47
| Facility | | $2,691.53 | $4,897.79 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Professional | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Facility | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,949.84 / $19,054.61
| Facility | | $1,621.81 | $1,949.84 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,511.89 / $2,511.89
| Facility | | $1,047.13 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,258.93 / $3,548.13
| Professional | | $1,047.13 | $1,258.93 | $3,548.13 |