- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,380.38 / $2,570.40
| Professional | | $1,148.15 | $1,380.38 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,698.24 / $2,511.89
| Professional | | $1,258.93 | $1,698.24 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,737.80 / $3,235.94
| Professional | | $977.24 | $1,737.80 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $4,073.80 / $9,549.93
| Facility | | $1,047.13 | $4,073.80 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,548.82 / $2,818.38
| Professional | | $1,148.15 | $1,548.82 | $2,818.38 |