- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,398.83
| Facility | | $1,096.48 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $912.01 / $1,659.59
| Professional | | $776.25 | $912.01 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,265.80 / $5,754.40
| Facility | | $3,630.78 | $4,265.80 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,122.02 / $1,445.44
| Professional | | $812.83 | $1,122.02 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,023.29 / $1,995.26
| Professional | | $660.69 | $1,023.29 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,365.16 / $6,918.31
| Facility | | $1,479.11 | $4,365.16 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $891.25 / $1,659.59
| Professional | | $616.60 | $891.25 | $1,659.59 |