- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $3,019.95
| Facility | | $1,698.24 | $2,511.89 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $3,630.78
| Professional | | $2,041.74 | $2,398.83 | $3,630.78 |
- 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
- $1,862.09 / $2,951.21 / $4,073.80
| Professional | | $1,862.09 | $2,951.21 | $4,073.80 |
- 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
- $1,949.84 / $2,691.53 / $4,265.80
| Professional | | $1,949.84 | $2,691.53 | $4,265.80 |