- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,532.90 / $2,392.44 / $5,755.37
| Facility | | $1,532.90 | $2,392.44 | $5,755.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.39 / $2,248.73 / $3,213.85
| Professional | | $1,334.39 | $2,248.73 | $3,213.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,328.39 / $2,183.27 / $4,531.79
| Facility | | $1,328.39 | $2,183.27 | $4,531.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,198.80 / $1,973.16 / $2,718.67
| Professional | | $1,198.80 | $1,973.16 | $2,718.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $880.27 / $984.63 / $1,737.93
| Facility | | $880.27 | $984.63 | $1,737.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,066.00 / $5,066.00 / $5,066.00
| Professional | | $5,066.00 | $5,066.00 | $5,066.00 |