- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,681.77 / $3,803.08 / $9,148.83
| Facility | | $2,681.77 | $3,803.08 | $9,148.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,254.27 / $3,666.65 / $5,192.89
| Professional | | $2,254.27 | $3,666.65 | $5,192.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,180.08 / $3,476.93 / $7,203.80
| Facility | | $2,180.08 | $3,476.93 | $7,203.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.62 / $3,261.09 / $4,321.64
| Professional | | $1,905.62 | $3,261.09 | $4,321.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,464.84 / $2,464.84 / $2,464.84
| Facility | | $2,464.84 | $2,464.84 | $2,464.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,711.23 / $8,711.23 / $8,711.23
| Professional | | $8,711.23 | $8,711.23 | $8,711.23 |