- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,890.45 / $8,511.38
| Facility | | $1,288.25 | $3,890.45 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $812.83 / $1,479.11
| Professional | | $724.44 | $812.83 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,023.29 / $1,258.93
| Professional | | $812.83 | $1,023.29 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,691.53 / $7,244.36
| Facility | | $812.83 | $2,691.53 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $977.24 / $7,079.46
| Professional | | $741.31 | $977.24 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,073.80 / $8,317.64
| Facility | | $1,230.27 | $4,073.80 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $870.96 / $1,230.27
| Professional | | $691.83 | $870.96 | $1,230.27 |