- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,630.27 / $3,388.44
| Facility | | $2,290.87 | $2,630.27 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,737.80 / $2,187.76
| Professional | | $1,380.38 | $1,737.80 | $2,187.76 |
- 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
- $1,230.27 / $1,479.11 / $1,905.46
| Professional | | $1,230.27 | $1,479.11 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,862.09 / $4,897.79
| Facility | | $1,445.44 | $1,862.09 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $2,041.74 / $2,290.87
| Facility | | $954.99 | $2,041.74 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $1,380.38
| Professional | | $954.99 | $954.99 | $1,380.38 |