- 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
- $645.65 / $758.58 / $1,047.13
| Professional | | $645.65 | $758.58 | $1,047.13 |
- 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
- $1,047.13 / $1,479.11 / $1,778.28
| Professional | | $1,047.13 | $1,479.11 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $741.31 / $1,621.81
| Professional | | $575.44 | $741.31 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,737.80 / $3,388.44
| Facility | | $645.65 | $1,737.80 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $691.83 / $831.76
| Professional | | $588.84 | $691.83 | $831.76 |