- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,995.26 / $2,951.21
| Facility | | $1,949.84 | $1,995.26 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $1,995.26
| Professional | | $1,047.13 | $1,479.11 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $891.25
| Facility | | $549.54 | $660.69 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,258.93 / $1,659.59
| Professional | | $758.58 | $1,258.93 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,584.89 / $3,801.89
| Facility | | $1,122.02 | $1,584.89 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,584.89 / $1,737.80
| Facility | | $741.31 | $1,584.89 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $812.83 / $1,047.13
| Professional | | $741.31 | $812.83 | $1,047.13 |