- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,935.52 / $2,744.81 / $6,603.02
| Facility | | $1,935.52 | $2,744.81 | $6,603.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.91 / $2,363.94 / $3,634.42
| Professional | | $1,479.91 | $2,363.94 | $3,634.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,573.44 / $2,509.42 / $5,199.22
| Facility | | $1,573.44 | $2,509.42 | $5,199.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.58 / $1,961.34 / $3,119.08
| Professional | | $1,301.58 | $1,961.34 | $3,119.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,526.21 / $1,526.21 / $1,526.21
| Facility | | $1,526.21 | $1,526.21 | $1,526.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,903.12 / $5,903.12 / $5,903.12
| Professional | | $5,903.12 | $5,903.12 | $5,903.12 |