- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,862.09 / $2,691.53
| Facility | | $1,380.38 | $1,862.09 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,584.89 / $2,454.71
| Professional | | $1,380.38 | $1,584.89 | $2,454.71 |
- 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
- $1,479.11 / $2,137.96 / $2,884.03
| Professional | | $1,479.11 | $2,137.96 | $2,884.03 |
- 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
- $1,445.44 / $1,905.46 / $2,884.03
| Professional | | $1,445.44 | $1,905.46 | $2,884.03 |