- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,548.13 / $3,981.07
| Facility | | $1,949.84 | $3,548.13 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,584.89 / $3,548.13
| Professional | | $1,445.44 | $1,584.89 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,318.26 / $1,479.11
| Facility | | $1,258.93 | $1,318.26 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,344.23
| Facility | | $1,737.80 | $1,737.80 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $4,365.16
| Professional | | $812.83 | $1,174.90 | $4,365.16 |