- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,570.40 / $3,311.31
| Facility | | $2,238.72 | $2,570.40 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $2,570.40
| Professional | | $1,479.11 | $1,737.80 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $891.25
| Facility | | $549.54 | $660.69 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,819.70 / $4,786.30
| Facility | | $1,445.44 | $1,819.70 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,162.28
| Professional | | $2,570.40 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,995.26 / $2,238.72
| Facility | | $933.25 | $1,995.26 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $2,238.72
| Professional | | $933.25 | $1,122.02 | $2,238.72 |