- 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
- $724.44 / $954.99 / $1,445.44
| Professional | | $724.44 | $954.99 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,023.29
| Professional | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,388.44 / $4,570.88
| Facility | | $2,818.38 | $3,388.44 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,096.48 / $1,380.38
| Professional | | $758.58 | $1,096.48 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $933.25 / $1,412.54
| Professional | | $457.09 | $933.25 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,884.03 / $4,073.80
| Facility | | $831.76 | $2,884.03 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $812.83 / $1,318.26
| Professional | | $602.56 | $812.83 | $1,318.26 |