- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,410.91 / $2,001.87 / $4,815.78
| Facility | | $1,410.91 | $2,001.87 | $4,815.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.46 / $1,392.54 / $2,411.32
| Professional | | $810.46 | $1,392.54 | $2,411.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,257.97 / $1,830.19 / $3,791.95
| Facility | | $1,257.97 | $1,830.19 | $3,791.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.35 / $1,246.39 / $2,198.76
| Professional | | $780.35 | $1,246.39 | $2,198.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $521.44 / $668.96 / $1,098.05
| Facility | | $521.44 | $668.96 | $1,098.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.00 / $2,955.00 / $2,955.00
| Professional | | $1,040.00 | $2,955.00 | $2,955.00 |