- 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
- $1,318.26 / $1,513.56 / $3,548.13
| Professional | | $1,318.26 | $1,513.56 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Professional | | $1,737.80 | $1,737.80 | $1,737.80 |
- 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
- $741.31 / $1,047.13 / $4,365.16
| Professional | | $741.31 | $1,047.13 | $4,365.16 |