- 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
- $524.81 / $616.60 / $1,023.29
| Professional | | $524.81 | $616.60 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,162.28 / $4,265.80
| Facility | | $2,691.53 | $3,162.28 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $741.31 / $870.96
| Professional | | $524.81 | $741.31 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $660.69 / $1,023.29
| Professional | | $407.38 | $660.69 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,630.78 / $5,370.32
| Facility | | $1,122.02 | $3,630.78 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $588.84 / $891.25
| Professional | | $416.87 | $588.84 | $891.25 |