- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,159.42 / $3,696.52 / $6,318.84
| Facility | | $3,159.42 | $3,696.52 | $6,318.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,685.51 / $3,696.52 / $3,696.52
| Professional | | $2,685.51 | $3,696.52 | $3,696.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.89 / $652.76 / $878.17
| Facility | | $537.89 | $652.76 | $878.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,049.98 / $2,582.52 / $3,047.37
| Professional | | $2,049.98 | $2,582.52 | $3,047.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,053.62 / $2,567.03 / $6,838.55
| Facility | | $2,053.62 | $2,567.03 | $6,838.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,843.48 / $3,159.42 / $3,159.42
| Facility | | $2,843.48 | $3,159.42 | $3,159.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,326.96 / $1,895.65
| Professional | | $1,326.96 | $1,326.96 | $1,895.65 |