- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,041.74 / $3,801.89
| Facility | | $1,737.80 | $2,041.74 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $831.76 / $1,412.54
| Professional | | $602.56 | $831.76 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,884.03 / $4,677.35
| Facility | | $2,187.76 | $2,884.03 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,047.13 / $2,238.72
| Professional | | $676.08 | $1,047.13 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $5,754.40
| Facility | | $1,122.02 | $1,122.02 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,235.94 / $3,801.89
| Professional | | $2,344.23 | $3,235.94 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $676.08 / $2,290.87
| Professional | | $616.60 | $676.08 | $2,290.87 |