- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,737.80 / $5,248.07
| Facility | | $1,318.26 | $1,737.80 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,348.96 / $1,905.46
| Professional | | $1,174.90 | $1,348.96 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $4,677.35
| Facility | | $1,122.02 | $1,122.02 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,511.89
| Professional | | $2,137.96 | $2,137.96 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,737.80 / $3,019.95
| Facility | | $1,288.25 | $1,737.80 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $6,606.93
| Professional | | $724.44 | $724.44 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,737.80 / $2,089.30
| Facility | | $724.44 | $1,737.80 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $1,148.15
| Professional | | $724.44 | $724.44 | $1,148.15 |