- 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
- $562.34 / $724.44 / $1,348.96
| Professional | | $562.34 | $724.44 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,570.40 / $3,467.37
| Facility | | $2,137.96 | $2,570.40 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $831.76 / $1,023.29
| Professional | | $588.84 | $831.76 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $724.44 / $1,071.52
| Professional | | $436.52 | $724.44 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,951.21 / $4,365.16
| Facility | | $831.76 | $2,951.21 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $602.56 / $977.24
| Professional | | $457.09 | $602.56 | $977.24 |