- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.53 / $2,305.53 / $4,222.21
| Facility | | $1,400.53 | $2,305.53 | $4,222.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.91 / $1,229.61 / $1,383.32
| Professional | | $1,075.91 | $1,229.61 | $1,383.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $556.80 / $2,255.58 / $5,994.38
| Facility | | $556.80 | $2,255.58 | $5,994.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.79 / $597.16 / $1,537.02
| Professional | | $514.79 | $597.16 | $1,537.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,098.58 / $2,384.10 / $4,717.66
| Facility | | $1,098.58 | $2,384.10 | $4,717.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,872.39 / $1,872.39 / $2,243.33
| Professional | | $1,872.39 | $1,872.39 | $2,243.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,537.02 / $1,537.02 / $1,844.42
| Facility | | $1,537.02 | $1,537.02 | $1,844.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.54 / $922.21 / $2,052.23
| Professional | | $645.54 | $922.21 | $2,052.23 |