- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,949.84 / $5,888.44
| Facility | | $1,318.26 | $1,949.84 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,479.11 / $1,995.26
| Professional | | $1,230.27 | $1,479.11 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $5,248.07
| Facility | | $1,258.93 | $1,258.93 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,818.38
| Professional | | $2,398.83 | $2,398.83 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,949.84 / $3,388.44
| Facility | | $1,288.25 | $1,949.84 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $6,606.93
| Professional | | $741.31 | $741.31 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,949.84 / $2,344.23
| Facility | | $812.83 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $1,148.15
| Professional | | $741.31 | $741.31 | $1,148.15 |