- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,613.79 / $2,289.73 / $5,508.26
| Facility | | $1,613.79 | $2,289.73 | $5,508.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,240.89 / $1,972.02 / $2,837.27
| Professional | | $1,240.89 | $1,972.02 | $2,837.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,467.08 / $2,093.36 / $4,337.21
| Facility | | $1,467.08 | $2,093.36 | $4,337.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.79 / $1,721.51 / $2,601.94
| Professional | | $1,085.79 | $1,721.51 | $2,601.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $727.60 / $982.40 / $1,704.58
| Facility | | $727.60 | $982.40 | $1,704.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.00 / $3,225.29 / $3,225.29
| Professional | | $1,311.00 | $3,225.29 | $3,225.29 |