- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $3,162.28
| Facility | | $1,698.24 | $2,511.89 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,344.23 / $3,548.13
| Professional | | $1,995.26 | $2,344.23 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $562.34
| Facility | | $512.86 | $512.86 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,019.95 / $3,981.07
| Professional | | $2,137.96 | $3,019.95 | $3,981.07 |
- 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
- $1,995.26 / $2,630.27 / $4,168.69
| Professional | | $1,995.26 | $2,630.27 | $4,168.69 |