- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,691.53 / $3,715.35
| Facility | | $2,187.76 | $2,691.53 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,819.70 / $2,691.53
| Professional | | $1,288.25 | $1,819.70 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $3,311.31
| Facility | | $2,398.83 | $2,398.83 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,884.03
| Professional | | $1,905.46 | $1,905.46 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,754.23 / $3,981.07
| Facility | | $1,380.38 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,137.96
| Facility | | $1,905.46 | $1,905.46 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,288.25 / $2,137.96
| Professional | | $891.25 | $1,288.25 | $2,137.96 |