- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,819.70 / $2,454.71
| Facility | | $1,659.59 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,445.44 / $2,238.72
| Professional | | $1,258.93 | $1,445.44 | $2,238.72 |
- 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
- $1,318.26 / $1,905.46 / $2,454.71
| Professional | | $1,318.26 | $1,905.46 | $2,454.71 |
- 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
- $1,258.93 / $1,621.81 / $2,570.40
| Professional | | $1,258.93 | $1,621.81 | $2,570.40 |