- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,137.96 / $2,630.27
| Facility | | $1,258.93 | $2,137.96 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,230.27 / $3,467.37
| Professional | | $977.24 | $1,230.27 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,754.40 / $7,762.47
| Facility | | $4,786.30 | $5,754.40 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $1,737.80
| Professional | | $1,096.48 | $1,548.82 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,096.48 / $1,819.70
| Professional | | $758.58 | $1,096.48 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,365.16 / $6,918.31
| Facility | | $1,479.11 | $4,365.16 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $977.24 / $1,584.89
| Professional | | $758.58 | $977.24 | $1,584.89 |