- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,548.13 / $9,772.37
| Facility | | $2,137.96 | $3,548.13 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,715.35 / $4,897.79
| Facility | | $1,778.28 | $3,715.35 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,412.54 / $1,513.56
| Professional | | $1,202.26 | $1,412.54 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $1,698.24
| Facility | | $870.96 | $1,445.44 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Professional | | $1,318.26 | $1,318.26 | $1,318.26 |