- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $3,090.30
| Facility | | $2,238.72 | $2,238.72 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,513.56 / $2,238.72
| Professional | | $1,174.90 | $1,513.56 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $2,398.83
| Professional | | $1,584.89 | $1,584.89 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,412.54 / $3,311.31
| Facility | | $1,148.15 | $1,412.54 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $1,778.28
| Facility | | $1,584.89 | $1,584.89 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,071.52 / $1,778.28
| Professional | | $741.31 | $1,071.52 | $1,778.28 |