- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,851.30 / $2,625.37 / $6,315.68
| Facility | | $1,851.30 | $2,625.37 | $6,315.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.64 / $1,416.67 / $2,341.92
| Professional | | $1,126.64 | $1,416.67 | $2,341.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,457.71 / $2,400.21 / $4,972.97
| Facility | | $1,457.71 | $2,400.21 | $4,972.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.49 / $1,115.49 / $2,049.17
| Professional | | $1,115.49 | $1,115.49 | $2,049.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,011.55 / $1,159.58 / $1,722.87
| Facility | | $1,011.55 | $1,159.58 | $1,722.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,816.68 / $3,816.68 / $3,816.68
| Professional | | $3,816.68 | $3,816.68 | $3,816.68 |