- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,715.35 / $5,888.44
| Facility | | $3,162.28 | $3,715.35 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,187.76 / $3,235.94
| Professional | | $1,905.46 | $2,187.76 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $2,511.89
| Facility | | $1,479.11 | $1,737.80 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,778.28 / $7,762.47
| Facility | | $1,479.11 | $1,778.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $8,912.51 / $8,912.51
| Professional | | $1,584.89 | $8,912.51 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $7,762.47 / $7,762.47
| Facility | | $5,248.07 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,912.51 / $8,912.51
| Professional | | $4,570.88 | $8,912.51 | $8,912.51 |