- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,487.37 / $2,721.89 / $3,019.36
| Facility | | $1,487.37 | $2,721.89 | $3,019.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,175.02 / $1,636.11 / $2,855.75
| Professional | | $1,175.02 | $1,636.11 | $2,855.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,487.37 / $1,487.37 / $1,487.37
| Facility | | $1,487.37 | $1,487.37 | $1,487.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.37 / $1,487.37 / $1,487.37
| Professional | | $1,487.37 | $1,487.37 | $1,487.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.81 / $966.79 / $1,247.16
| Facility | | $53.81 | $966.79 | $1,247.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $677.34 / $1,393.89 / $2,136.23
| Professional | | $677.34 | $1,393.89 | $2,136.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.70 / $743.69 / $2,231.06
| Professional | | $624.70 | $743.69 | $2,231.06 |