- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,890.45 / $7,943.28
| Facility | | $2,041.74 | $3,890.45 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $2,238.72 / $4,786.30
| Professional | | $645.65 | $2,238.72 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $2,511.89 / $3,801.89
| Facility | | $776.25 | $2,511.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $2,290.87
| Professional | | $1,148.15 | $1,148.15 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,412.54 / $2,238.72
| Facility | | $371.54 | $1,412.54 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $1,122.02 / $2,187.76
| Facility | | $257.04 | $1,122.02 | $2,187.76 |