- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,698.24 / $4,073.80
| Facility | | $1,174.90 | $1,698.24 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,348.96 / $2,041.74
| Professional | | $870.96 | $1,348.96 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,621.81 / $3,162.28
| Facility | | $1,318.26 | $1,621.81 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $1,819.70
| Professional | | $812.83 | $1,148.15 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Professional | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $524.81 / $870.96
| Professional | | $416.87 | $524.81 | $870.96 |