- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,044.30 / $2,166.91 / $2,861.38
| Facility | | $1,044.30 | $2,166.91 | $2,861.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.07 / $1,031.24 / $1,044.30
| Professional | | $868.07 | $1,031.24 | $1,044.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $991.88 / $1,696.98 / $3,426.85
| Facility | | $991.88 | $1,696.98 | $3,426.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.02 / $1,500.02 / $1,875.02
| Professional | | $1,500.02 | $1,500.02 | $1,875.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $783.22 / $1,044.30 / $1,305.36
| Facility | | $783.22 | $1,044.30 | $1,305.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.49 / $1,305.36 / $1,305.36
| Professional | | $848.49 | $1,305.36 | $1,305.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.41 / $652.69 / $1,305.36
| Professional | | $587.41 | $652.69 | $1,305.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,271.34 / $6,200.51 / $6,200.51
| Facility | | $2,271.34 | $6,200.51 | $6,200.51 |