- 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
- $331.13 / $1,096.48 / $2,511.89
| Professional | | $331.13 | $1,096.48 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $2,511.89
| Facility | | $1,548.82 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $1,023.29 / $1,621.81
| Professional | | $234.42 | $1,023.29 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $489.78 / $2,041.74
| Professional | | $269.15 | $489.78 | $2,041.74 |
- 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
- $275.42 / $1,047.13 / $1,819.70
| Professional | | $275.42 | $1,047.13 | $1,819.70 |