- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,090.30 / $6,760.83
| Facility | | $1,659.59 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $1,318.26 / $3,981.07
| Professional | | $489.78 | $1,318.26 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,318.26 / $1,995.26
| Facility | | $416.87 | $1,318.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $954.99 / $2,754.23
| Professional | | $851.14 | $954.99 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,412.54 / $2,238.72
| Facility | | $707.95 | $1,412.54 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.93 / $1,122.02 / $2,187.76
| Facility | | $208.93 | $1,122.02 | $2,187.76 |