- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,981.07 / $4,466.84
| Facility | | $2,187.76 | $3,981.07 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,737.80 / $2,398.83
| Professional | | $1,445.44 | $1,737.80 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,951.21 / $2,951.21
| Facility | | $2,884.03 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,513.56
| Facility | | $1,445.44 | $1,445.44 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Professional | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,630.27
| Facility | | $1,995.26 | $1,995.26 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $4,897.79
| Professional | | $933.25 | $1,318.26 | $4,897.79 |