- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $3,801.89
| Facility | | $1,148.15 | $1,621.81 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,348.96 / $1,949.84
| Professional | | $870.96 | $1,348.96 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,548.82 / $3,019.95
| Facility | | $1,230.27 | $1,548.82 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,174.90 / $1,778.28
| Professional | | $831.76 | $1,174.90 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $575.44 / $1,096.48
| Facility | | $436.52 | $575.44 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,137.96
| Professional | | $2,089.30 | $2,089.30 | $2,137.96 |