- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,584.89 / $3,801.89
| Facility | | $1,122.02 | $1,584.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,318.26 / $1,905.46
| Professional | | $851.14 | $1,318.26 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,513.56 / $2,951.21
| Facility | | $1,230.27 | $1,513.56 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,071.52 / $1,698.24
| Professional | | $812.83 | $1,071.52 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $537.03 / $1,047.13
| Facility | | $407.38 | $537.03 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $2,089.30 / $2,089.30
| Professional | | $575.44 | $2,089.30 | $2,089.30 |