- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $457.09 / $812.83
| Professional | | $354.81 | $457.09 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $575.44 / $812.83
| Professional | | $426.58 | $575.44 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,174.90 / $1,174.90
| Facility | | $588.84 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $549.54 / $1,047.13
| Professional | | $354.81 | $549.54 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,398.83 / $5,495.41
| Facility | | $794.33 | $2,398.83 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $501.19 / $933.25
| Professional | | $354.81 | $501.19 | $933.25 |