- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,238.72
| Facility | | $870.96 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $691.83 / $1,202.26
| Professional | | $588.84 | $691.83 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,786.30 / $6,456.54
| Facility | | $3,981.07 | $4,786.30 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $891.25 / $1,148.15
| Professional | | $616.60 | $891.25 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $776.25 / $1,288.25
| Professional | | $501.19 | $776.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,737.80 / $3,090.30
| Facility | | $645.65 | $1,737.80 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $676.08 / $1,071.52
| Professional | | $501.19 | $676.08 | $1,071.52 |