- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $3,890.45
| Facility | | $1,148.15 | $1,621.81 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,348.96 / $1,949.84
| Professional | | $870.96 | $1,348.96 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $3,090.30
| Facility | | $1,258.93 | $1,548.82 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,096.48 / $1,778.28
| Professional | | $831.76 | $1,096.48 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $645.65 / $1,318.26
| Facility | | $616.60 | $645.65 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $6,309.57 / $6,309.57
| Professional | | $724.44 | $6,309.57 | $6,309.57 |