- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,737.80 / $2,454.71
| Facility | | $1,548.82 | $1,737.80 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,412.54 / $2,089.30
| Professional | | $1,202.26 | $1,412.54 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $537.03 / $562.34
| Facility | | $512.86 | $537.03 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,698.24 / $2,344.23
| Professional | | $1,202.26 | $1,698.24 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $758.58 / $2,570.40
| Facility | | $371.54 | $758.58 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,548.82 / $2,454.71
| Professional | | $1,148.15 | $1,548.82 | $2,454.71 |