- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,819.70 / $2,511.89
| Facility | | $1,698.24 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,548.82 / $2,290.87
| Professional | | $1,318.26 | $1,548.82 | $2,290.87 |
- 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
- $1,288.25 / $1,862.09 / $2,570.40
| Professional | | $1,288.25 | $1,862.09 | $2,570.40 |
- 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
- $1,230.27 / $1,659.59 / $2,630.27
| Professional | | $1,230.27 | $1,659.59 | $2,630.27 |