- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,981.07 / $6,760.83
| Facility | | $1,584.89 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,548.82 / $3,890.45
| Professional | | $1,000.00 | $1,548.82 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,691.53 / $7,244.36
| Facility | | $1,584.89 | $2,691.53 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,511.89 / $4,168.69
| Professional | | $2,187.76 | $2,511.89 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |