- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,388.44 / $6,606.93
| Facility | | $1,698.24 | $3,388.44 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,445.44 / $1,737.80
| Professional | | $1,174.90 | $1,445.44 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Professional | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,548.13 / $3,981.07
| Facility | | $1,778.28 | $3,548.13 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,862.09 / $2,511.89
| Facility | | $1,513.56 | $1,862.09 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $9,772.37
| Professional | | $741.31 | $1,047.13 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,949.84 / $2,089.30
| Facility | | $741.31 | $1,949.84 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $2,290.87
| Professional | | $741.31 | $1,047.13 | $2,290.87 |