- 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
- $741.31 / $912.01 / $1,288.25
| Professional | | $741.31 | $912.01 | $1,288.25 |
- 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
- $602.56 / $870.96 / $1,047.13
| Professional | | $602.56 | $870.96 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $851.14 / $1,819.70
| Professional | | $676.08 | $851.14 | $1,819.70 |
- 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
- $691.83 / $831.76 / $1,023.29
| Professional | | $691.83 | $831.76 | $1,023.29 |