- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,995.26 / $4,677.35
| Facility | | $1,412.54 | $1,995.26 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,698.24 / $2,511.89
| Professional | | $1,096.48 | $1,698.24 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,905.46 / $3,715.35
| Facility | | $1,513.56 | $1,905.46 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,412.54 / $2,137.96
| Professional | | $1,023.29 | $1,412.54 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $851.14 / $1,479.11
| Facility | | $676.08 | $851.14 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Professional | | $2,884.03 | $2,884.03 | $2,884.03 |