- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,454.71 / $2,454.71
| Facility | | $1,548.82 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $524.81 / $1,513.56
| Professional | | $398.11 | $524.81 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.03 / $831.76 / $1,047.13
| Facility | | $123.03 | $831.76 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,202.26 / $2,137.96
| Facility | | $1,122.02 | $1,202.26 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $138.04
| Professional | | $109.65 | $109.65 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |