- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,002.07 / $2,087.64 / $4,008.27
| Facility | | $1,002.07 | $2,087.64 | $4,008.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.07 / $1,670.11 / $1,670.11
| Professional | | $1,002.07 | $1,670.11 | $1,670.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,070.94 / $2,177.83 / $2,177.83
| Professional | | $2,070.94 | $2,177.83 | $2,177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,683.47 / $1,683.47 / $1,683.47
| Facility | | $1,683.47 | $1,683.47 | $1,683.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.57 / $1,409.57 / $1,603.31
| Professional | | $1,409.57 | $1,409.57 | $1,603.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.16 / $561.16 / $801.65
| Professional | | $561.16 | $561.16 | $801.65 |