- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,162.28 / $4,168.69
| Facility | | $2,754.23 | $3,162.28 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $2,238.72 / $3,162.28
| Professional | | $457.09 | $2,238.72 | $3,162.28 |
- 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
- $549.54 / $1,737.80 / $2,570.40
| Professional | | $549.54 | $1,737.80 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,238.72 / $6,025.60
| Facility | | $1,737.80 | $2,238.72 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,454.71 / $2,754.23
| Facility | | $1,148.15 | $2,454.71 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,659.59
| Professional | | $1,148.15 | $1,148.15 | $1,659.59 |