- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,201.62 / $4,028.97 / $4,469.29
| Facility | | $2,201.62 | $4,028.97 | $4,469.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,739.28 / $2,421.78 / $4,227.10
| Professional | | $1,739.28 | $2,421.78 | $4,227.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,201.62 / $2,201.62 / $2,201.62
| Facility | | $2,201.62 | $2,201.62 | $2,201.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,201.62 / $2,201.62 / $2,201.62
| Professional | | $2,201.62 | $2,201.62 | $2,201.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.63 / $2,529.63 / $3,162.03
| Professional | | $2,529.63 | $2,529.63 | $3,162.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.68 / $1,100.81 / $3,758.10
| Professional | | $924.68 | $1,100.81 | $3,758.10 |