- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,397.42 / $1,863.22 / $4,471.72
| Facility | | $1,397.42 | $1,863.22 | $4,471.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.78 / $1,378.78 / $1,993.65
| Professional | | $1,378.78 | $1,378.78 | $1,993.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,211.08 / $1,211.08 / $1,634.97
| Facility | | $1,211.08 | $1,211.08 | $1,634.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,269.44 / $2,269.44 / $2,719.06
| Professional | | $2,269.44 | $2,269.44 | $2,719.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,378.78 / $1,467.29 / $3,074.31
| Facility | | $1,378.78 | $1,467.29 | $3,074.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $782.55 / $2,329.03
| Professional | | $782.55 | $782.55 | $2,329.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $782.55 / $1,192.46
| Professional | | $782.55 | $782.55 | $1,192.46 |