- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.29 / $3,566.58 / $8,579.90
| Facility | | $2,126.29 | $3,566.58 | $8,579.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.55 / $1,566.19 / $2,172.94
| Professional | | $1,245.55 | $1,566.19 | $2,172.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.26 / $3,260.71 / $6,755.83
| Facility | | $1,949.26 | $3,260.71 | $6,755.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.22 / $1,233.22 / $1,949.26
| Professional | | $1,233.22 | $1,233.22 | $1,949.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,015.54 / $3,015.54 / $3,015.54
| Facility | | $3,015.54 | $3,015.54 | $3,015.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,961.58 / $4,961.58 / $4,961.58
| Professional | | $4,961.58 | $4,961.58 | $4,961.58 |