- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,238.72
| Facility | | $870.96 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $933.25 / $1,737.80
| Professional | | $758.58 | $933.25 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,884.03 / $3,890.45
| Facility | | $2,454.71 | $2,884.03 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,819.70 / $2,137.96
| Professional | | $1,202.26 | $1,819.70 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $851.14 / $1,862.09
| Professional | | $660.69 | $851.14 | $1,862.09 |
- 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
- $691.83 / $851.14 / $1,023.29
| Professional | | $691.83 | $851.14 | $1,023.29 |