- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,222.33 / $2,463.54 / $2,463.54
| Facility | | $1,222.33 | $2,463.54 | $2,463.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $557.65 / $557.94 / $698.31
| Professional | | $557.65 | $557.94 | $698.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,266.85 / $4,105.52 / $4,560.81
| Facility | | $3,266.85 | $4,105.52 | $4,560.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.05 / $1,099.33 / $1,594.04
| Professional | | $774.05 | $1,099.33 | $1,594.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,497.44 / $2,463.17 / $4,333.29
| Facility | | $1,497.44 | $2,463.17 | $4,333.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.72 / $1,660.42 / $2,379.67
| Professional | | $974.72 | $1,660.42 | $2,379.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.48 / $1,688.25 / $3,152.76
| Professional | | $886.48 | $1,688.25 | $3,152.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.88 / $948.88 / $3,152.76
| Professional | | $668.88 | $948.88 | $3,152.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.04 / $656.76 / $835.87
| Professional | | $597.04 | $656.76 | $835.87 |