- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.59 / $1,920.65 / $4,620.39
| Facility | | $1,230.59 | $1,920.65 | $4,620.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.24 / $1,805.27 / $2,580.06
| Professional | | $1,071.24 | $1,805.27 | $2,580.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,066.43 / $1,752.72 / $3,638.10
| Facility | | $1,066.43 | $1,752.72 | $3,638.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.39 / $1,584.04 / $2,182.54
| Professional | | $962.39 | $1,584.04 | $2,182.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $531.09 / $866.45 / $1,552.65
| Facility | | $531.09 | $866.45 | $1,552.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,018.40 / $3,018.40 / $3,018.40
| Professional | | $3,018.40 | $3,018.40 | $3,018.40 |