- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,588.07 / $2,071.30 / $3,031.18
| Facility | | $1,588.07 | $2,071.30 | $3,031.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,071.30 / $3,031.18 / $3,410.07
| Professional | | $2,071.30 | $3,031.18 | $3,410.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $921.78 / $921.78 / $921.78
| Professional | | $921.78 | $921.78 | $921.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $927.17 / $2,147.08 / $2,147.08
| Facility | | $927.17 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.08 / $2,147.08 / $2,147.08
| Professional | | $2,147.08 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.37 / $772.64 / $1,931.18
| Professional | | $695.37 | $772.64 | $1,931.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,020.78 / $2,104.98 / $2,736.47
| Professional | | $2,020.78 | $2,104.98 | $2,736.47 |