- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $3,981.07
| Facility | | $1,548.82 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,584.89 / $1,995.26
| Professional | | $1,479.11 | $1,584.89 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,365.16 / $5,011.87
| Professional | | $3,235.94 | $4,365.16 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $3,162.28
| Professional | | $2,511.89 | $2,511.89 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,659.59 / $3,981.07
| Facility | | $1,318.26 | $1,659.59 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $2,630.27 / $4,365.16
| Professional | | $933.25 | $2,630.27 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $2,238.72 / $3,715.35
| Professional | | $933.25 | $2,238.72 | $3,715.35 |