- 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
- $794.33 / $954.99 / $1,737.80
| Professional | | $794.33 | $954.99 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,623.41 / $7,585.78
| Facility | | $4,677.35 | $5,623.41 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,202.26 / $1,412.54
| Professional | | $794.33 | $1,202.26 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Facility | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,047.13 / $1,995.26
| Professional | | $691.83 | $1,047.13 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,265.80 / $6,309.57
| Facility | | $1,479.11 | $4,265.80 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $891.25 / $1,548.82
| Professional | | $691.83 | $891.25 | $1,548.82 |