- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,819.70 / $3,548.13
| Facility | | $1,380.38 | $1,819.70 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $1,380.38 / $1,819.70
| Professional | | $354.81 | $1,380.38 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,715.35 / $4,365.16
| Professional | | $2,570.40 | $3,715.35 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,818.38
| Professional | | $2,238.72 | $2,238.72 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $1,380.38 / $3,548.13
| Facility | | $354.81 | $1,380.38 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $2,290.87 / $3,890.45
| Professional | | $812.83 | $2,290.87 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,995.26 / $3,311.31
| Professional | | $812.83 | $1,995.26 | $3,311.31 |