- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $4,570.88 / $7,413.10
| Facility | | $1,174.90 | $4,570.88 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $758.58 / $1,348.96
| Professional | | $602.56 | $758.58 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,890.45 / $11,220.18
| Facility | | $1,202.26 | $3,890.45 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,023.29 / $1,513.56
| Professional | | $660.69 | $1,023.29 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,174.90 / $4,786.30
| Facility | | $851.14 | $1,174.90 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,047.13 / $1,737.80
| Professional | | $707.95 | $1,047.13 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $977.24 / $3,801.89
| Professional | | $741.31 | $977.24 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,623.41 / $8,511.38
| Facility | | $1,513.56 | $5,623.41 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $870.96 / $1,513.56
| Professional | | $575.44 | $870.96 | $1,513.56 |