- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,068.97 / $1,897.43 / $2,519.39
| Facility | | $1,068.97 | $1,897.43 | $2,519.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $639.54 / $890.81 / $2,227.02
| Professional | | $639.54 | $890.81 | $2,227.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.17 / $1,142.06 / $2,740.94
| Facility | | $371.17 | $1,142.06 | $2,740.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.94 / $1,246.40 / $1,558.00
| Professional | | $690.94 | $1,246.40 | $1,558.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $742.34 / $1,336.21 / $1,855.85
| Facility | | $742.34 | $1,336.21 | $1,855.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,391.26 / $1,391.26 / $1,666.89
| Professional | | $1,391.26 | $1,391.26 | $1,666.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.06 / $1,142.06 / $1,199.16
| Professional | | $1,142.06 | $1,142.06 | $1,199.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $479.67 / $479.67 / $1,142.06
| Professional | | $479.67 | $479.67 | $1,142.06 |