- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,090.30 / $6,309.57
| Facility | | $1,445.44 | $3,090.30 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $933.25 / $1,288.25
| Professional | | $223.87 | $933.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,691.53 / $3,981.07
| Facility | | $831.76 | $2,691.53 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,290.87 / $4,677.35
| Facility | | $1,288.25 | $2,290.87 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,445.44 / $8,912.51
| Professional | | $1,047.13 | $1,445.44 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,691.53 / $5,495.41
| Facility | | $1,412.54 | $2,691.53 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,288.25 / $2,187.76
| Professional | | $1,023.29 | $1,288.25 | $2,187.76 |