- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,388.44 / $4,365.16
| Facility | | $2,884.03 | $3,388.44 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,290.87 / $2,818.38
| Professional | | $1,584.89 | $2,290.87 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $891.25
| Facility | | $549.54 | $660.69 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $602.56 / $1,905.46
| Professional | | $426.58 | $602.56 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,344.23 / $6,309.57
| Facility | | $1,862.09 | $2,344.23 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Professional | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,630.27 / $2,884.03
| Facility | | $1,230.27 | $2,630.27 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,737.80
| Professional | | $1,230.27 | $1,230.27 | $1,737.80 |