- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $4,466.84
| Facility | | $1,698.24 | $2,511.89 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,715.35 / $5,495.41
| Professional | | $3,162.28 | $3,715.35 | $5,495.41 |
- 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
- $3,019.95 / $4,365.16 / $6,309.57
| Professional | | $3,019.95 | $4,365.16 | $6,309.57 |
- 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
- $2,951.21 / $4,073.80 / $6,309.57
| Professional | | $2,951.21 | $4,073.80 | $6,309.57 |