- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,659.59 / $3,981.07
| Facility | | $1,148.15 | $1,659.59 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,348.96 / $1,995.26
| Professional | | $851.14 | $1,348.96 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,584.89 / $3,090.30
| Facility | | $1,288.25 | $1,584.89 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,122.02 / $1,778.28
| Professional | | $794.33 | $1,122.02 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $676.08 / $954.99
| Facility | | $416.87 | $676.08 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |