- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,656.55 / $6,203.52 / $9,585.67
| Facility | | $3,656.55 | $6,203.52 | $9,585.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,092.75 / $3,092.75 / $3,092.75
| Professional | | $3,092.75 | $3,092.75 | $3,092.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,653.85 / $4,917.43 / $6,807.19
| Facility | | $2,653.85 | $4,917.43 | $6,807.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,401.67 / $3,002.09 / $4,038.75
| Facility | | $2,401.67 | $3,002.09 | $4,038.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.88 / $1,801.25 / $15,010.45
| Professional | | $1,260.88 | $1,801.25 | $15,010.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.88 / $1,801.25 / $4,503.14
| Professional | | $1,260.88 | $1,801.25 | $4,503.14 |