- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,041.74 / $6,918.31
| Facility | | $1,380.38 | $2,041.74 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,235.94 / $5,011.87
| Professional | | $2,818.38 | $3,235.94 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $537.03 / $562.34
| Facility | | $512.86 | $537.03 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,168.69 / $5,623.41
| Professional | | $2,754.23 | $4,168.69 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $758.58 / $2,570.40
| Facility | | $371.54 | $758.58 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,715.35 / $5,888.44
| Professional | | $2,818.38 | $3,715.35 | $5,888.44 |