- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $12,882.50
| Facility | | $1,584.89 | $1,584.89 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,621.81 / $1,737.80
| Professional | | $1,479.11 | $1,621.81 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,698.24 / $1,862.09
| Professional | | $1,513.56 | $1,698.24 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,630.78 / $8,128.31
| Facility | | $3,467.37 | $3,630.78 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $4,365.16
| Professional | | $2,454.71 | $2,454.71 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Facility | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $954.99 / $2,630.27
| Professional | | $891.25 | $954.99 | $2,630.27 |