- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,398.83
| Facility | | $1,096.48 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $758.58 / $1,202.26
| Professional | | $588.84 | $758.58 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,778.28 / $2,398.83
| Facility | | $1,513.56 | $1,778.28 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $954.99 / $1,548.82
| Professional | | $602.56 | $954.99 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $758.58 / $2,238.72
| Professional | | $489.78 | $758.58 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,951.21 / $4,168.69
| Facility | | $831.76 | $2,951.21 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $707.95 / $933.25
| Professional | | $524.81 | $707.95 | $933.25 |