- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,630.27 / $6,760.83
| Facility | | $1,047.13 | $2,630.27 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $1,174.90 / $1,737.80
| Professional | | $338.84 | $1,174.90 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $602.56 / $2,398.83
| Professional | | $426.58 | $602.56 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $2,290.87 / $6,760.83
| Facility | | $426.58 | $2,290.87 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,862.09 / $9,120.11
| Professional | | $1,148.15 | $1,862.09 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,265.80 / $8,128.31
| Facility | | $1,230.27 | $4,265.80 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $1,047.13 / $2,290.87
| Professional | | $316.23 | $1,047.13 | $2,290.87 |