- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,663.24 / $3,776.80 / $9,085.61
| Facility | | $2,663.24 | $3,776.80 | $9,085.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.69 / $3,641.31 / $5,157.01
| Professional | | $2,238.69 | $3,641.31 | $5,157.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,165.02 / $3,452.90 / $7,154.03
| Facility | | $2,165.02 | $3,452.90 | $7,154.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,892.46 / $3,238.56 / $4,291.78
| Professional | | $1,892.46 | $3,238.56 | $4,291.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,432.45 / $1,497.03 / $2,650.43
| Facility | | $1,432.45 | $1,497.03 | $2,650.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,178.67 / $5,178.67 / $5,178.67
| Professional | | $5,178.67 | $5,178.67 | $5,178.67 |