- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,513.56 / $2,398.83
| Facility | | $1,023.29 | $1,513.56 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $794.33 / $1,122.02
| Professional | | $645.65 | $794.33 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,621.81 / $2,238.72
| Facility | | $1,380.38 | $1,621.81 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $891.25 / $1,047.13
| Professional | | $630.96 | $891.25 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $741.31 / $1,584.89
| Professional | | $575.44 | $741.31 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,630.78 / $5,128.61
| Facility | | $1,122.02 | $3,630.78 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $724.44 / $870.96
| Professional | | $602.56 | $724.44 | $870.96 |