- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,698.24 / $2,454.71
| Facility | | $1,318.26 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,230.27 / $1,819.70
| Professional | | $1,023.29 | $1,230.27 | $1,819.70 |
- 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
- $1,023.29 / $1,445.44 / $2,041.74
| Professional | | $1,023.29 | $1,445.44 | $2,041.74 |
- 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
- $977.24 / $1,348.96 / $2,089.30
| Professional | | $977.24 | $1,348.96 | $2,089.30 |