- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,513.56 / $2,290.87
| Facility | | $1,023.29 | $1,513.56 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $891.25 / $1,621.81
| Professional | | $645.65 | $891.25 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,630.78 / $4,897.79
| Facility | | $3,019.95 | $3,630.78 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $912.01 / $1,202.26
| Professional | | $602.56 | $912.01 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Facility | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $794.33 / $1,862.09
| Professional | | $575.44 | $794.33 | $1,862.09 |
- 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
- $630.96 / $794.33 / $1,380.38
| Professional | | $630.96 | $794.33 | $1,380.38 |