- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.42 / $2,198.35 / $5,016.85
| Facility | | $1,445.42 | $2,198.35 | $5,016.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.13 / $1,445.42 / $1,538.85
| Professional | | $1,165.13 | $1,445.42 | $1,538.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $556.80 / $3,226.08 / $5,440.92
| Facility | | $556.80 | $3,226.08 | $5,440.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $989.25 / $1,319.01 / $1,723.56
| Professional | | $989.25 | $1,319.01 | $1,723.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,428.93 / $7,070.72 / $12,618.20
| Facility | | $1,428.93 | $7,070.72 | $12,618.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.85 / $3,456.91 / $5,429.92
| Professional | | $1,538.85 | $3,456.91 | $5,429.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,099.18 / $1,319.01 / $2,891.27
| Professional | | $1,099.18 | $1,319.01 | $2,891.27 |