- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,949.84 / $2,511.89
| Facility | | $1,698.24 | $1,949.84 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,698.24 / $2,570.40
| Professional | | $1,479.11 | $1,698.24 | $2,570.40 |
- 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
- $1,412.54 / $1,862.09 / $2,951.21
| Professional | | $1,412.54 | $1,862.09 | $2,951.21 |