- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.75 / $1,816.84 / $5,131.74
| Facility | | $1,201.75 | $1,816.84 | $5,131.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.31 / $1,816.84 / $2,335.94
| Professional | | $1,730.31 | $1,816.84 | $2,335.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,005.12 / $1,005.12 / $1,105.63
| Facility | | $1,005.12 | $1,005.12 | $1,105.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.15 / $1,730.32 / $1,730.32
| Facility | | $891.15 | $1,730.32 | $1,730.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $1,730.32
| Professional | | $1,730.32 | $1,730.32 | $1,730.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,799.53 / $2,284.02
| Professional | | $1,730.32 | $1,799.53 | $2,284.02 |