- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,143.60 / $2,465.14 / $4,287.20
| Facility | | $2,143.60 | $2,465.14 | $4,287.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.16 / $2,465.14 / $2,465.14
| Professional | | $1,286.16 | $2,465.14 | $2,465.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.89 / $652.76 / $878.17
| Facility | | $537.89 | $652.76 | $878.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.14 / $369.21 / $529.15
| Professional | | $305.14 | $369.21 | $529.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $392.74 / $1,741.68 / $4,639.82
| Facility | | $392.74 | $1,741.68 | $4,639.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.01 / $1,254.01 / $3,078.92
| Professional | | $815.01 | $1,254.01 | $3,078.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.16 / $900.31 / $1,286.16
| Professional | | $331.16 | $900.31 | $1,286.16 |