- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $6,165.95 / $12,022.64
| Facility | | $1,737.80 | $6,165.95 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,995.26 / $2,754.23
| Professional | | $1,737.80 | $1,995.26 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,691.53 / $3,548.13
| Professional | | $2,511.89 | $2,691.53 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $6,309.57 / $14,454.40
| Facility | | $1,621.81 | $6,309.57 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,238.72 / $4,265.80
| Facility | | $1,862.09 | $2,238.72 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,511.89 / $3,019.95
| Facility | | $2,238.72 | $2,511.89 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $2,511.89
| Professional | | $1,047.13 | $1,513.56 | $2,511.89 |