- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,398.83 / $2,630.27
| Facility | | $1,318.26 | $2,398.83 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,023.29 / $1,445.44
| Professional | | $870.96 | $1,023.29 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $891.25
| Facility | | $851.14 | $851.14 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Professional | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,548.82
| Facility | | $1,174.90 | $1,174.90 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $776.25 / $2,884.03
| Professional | | $549.54 | $776.25 | $2,884.03 |