- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,981.07 / $5,248.07
| Facility | | $3,467.37 | $3,981.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $3,981.07
| Professional | | $2,089.30 | $3,019.95 | $3,981.07 |
- 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
- $426.58 / $602.56 / $2,290.87
| Professional | | $426.58 | $602.56 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,818.38 / $7,585.78
| Facility | | $2,290.87 | $2,818.38 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,162.28 / $3,467.37
| Facility | | $1,479.11 | $3,162.28 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $2,089.30
| Professional | | $1,479.11 | $1,479.11 | $2,089.30 |