- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,730.92 / $3,652.24 / $4,640.25
| Facility | | $1,730.92 | $3,652.24 | $4,640.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.91 / $1,730.92 / $1,730.92
| Professional | | $872.91 | $1,730.92 | $1,730.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $721.22 / $2,219.13 / $5,325.91
| Facility | | $721.22 | $2,219.13 | $5,325.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.57 / $1,549.20 / $1,628.84
| Professional | | $1,342.57 | $1,549.20 | $1,628.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,442.43 / $2,596.37 / $3,606.08
| Facility | | $1,442.43 | $2,596.37 | $3,606.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $2,549.86 / $3,187.33
| Professional | | $2,549.86 | $2,549.86 | $3,187.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,219.13 / $2,219.13 / $2,330.09
| Professional | | $2,219.13 | $2,219.13 | $2,330.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $932.03 / $2,219.13
| Professional | | $932.03 | $932.03 | $2,219.13 |