- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $851.14 / $3,090.30
| Professional | | $371.54 | $851.14 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $776.25 / $1,513.56
| Professional | | $380.19 | $776.25 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,348.96 / $1,348.96
| Facility | | $676.08 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $870.96 / $2,951.21
| Professional | | $426.58 | $870.96 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $3,548.13 / $7,413.10
| Facility | | $831.76 | $3,548.13 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $851.14 / $3,090.30
| Professional | | $380.19 | $851.14 | $3,090.30 |