- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,090.30 / $6,309.57
| Facility | | $1,445.44 | $3,090.30 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,238.72 / $4,786.30
| Professional | | $1,258.93 | $2,238.72 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,348.96 / $1,995.26
| Facility | | $416.87 | $1,348.96 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $676.08
| Professional | | $141.25 | $141.25 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,412.54 / $2,238.72
| Facility | | $794.33 | $1,412.54 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,412.54 / $2,187.76
| Facility | | $691.83 | $1,412.54 | $2,187.76 |