- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,862.09 / $2,398.83
| Facility | | $1,258.93 | $1,862.09 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $954.99 / $1,819.70
| Professional | | $758.58 | $954.99 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,760.83 / $9,120.11
| Facility | | $5,623.41 | $6,760.83 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,071.52 / $1,380.38
| Professional | | $758.58 | $1,071.52 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $933.25 / $1,445.44
| Professional | | $602.56 | $933.25 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,754.23 / $3,981.07
| Facility | | $812.83 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $831.76 / $1,288.25
| Professional | | $602.56 | $831.76 | $1,288.25 |