- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,388.44 / $4,365.16
| Facility | | $2,951.21 | $3,388.44 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,454.71 / $3,388.44
| Professional | | $1,737.80 | $2,454.71 | $3,388.44 |
- 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 / $1,905.46
| Professional | | $426.58 | $602.56 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,398.83 / $6,309.57
| Facility | | $1,905.46 | $2,398.83 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,630.27 / $2,951.21
| Facility | | $1,230.27 | $2,630.27 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,737.80
| Professional | | $1,230.27 | $1,230.27 | $1,737.80 |