- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,623.41 / $10,471.29
| Facility | | $1,949.84 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,778.28 / $3,162.28
| Professional | | $1,174.90 | $1,778.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $2,398.83 / $5,623.41
| Facility | | $954.99 | $2,398.83 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,238.72 / $11,481.54
| Professional | | $1,698.24 | $2,238.72 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,398.83 / $4,677.35
| Facility | | $1,548.82 | $2,398.83 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,137.96 / $3,019.95
| Professional | | $1,862.09 | $2,137.96 | $3,019.95 |