- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $2,818.38
| Facility | | $1,698.24 | $2,511.89 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,398.83 / $3,548.13
| Professional | | $1,995.26 | $2,398.83 | $3,548.13 |
- 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
- $1,949.84 / $2,884.03 / $3,890.45
| Professional | | $1,949.84 | $2,884.03 | $3,890.45 |
- 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
- $1,905.46 / $2,511.89 / $4,073.80
| Professional | | $1,905.46 | $2,511.89 | $4,073.80 |