- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,238.72 / $3,235.94
| Facility | | $2,089.30 | $2,238.72 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $602.56 / $1,548.82
| Facility | | $316.23 | $602.56 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,089.30 / $2,089.30
| Professional | | $1,659.59 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,737.80 / $2,691.53
| Facility | | $489.78 | $1,737.80 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,862.09 / $3,715.35
| Facility | | $602.56 | $1,862.09 | $3,715.35 |