- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,153.91 / $1,667.25 / $4,005.09
| Facility | | $1,153.91 | $1,667.25 | $4,005.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.15 / $1,153.91 / $1,228.50
| Professional | | $930.15 | $1,153.91 | $1,228.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.67 / $2,575.46 / $4,343.63
| Facility | | $457.67 | $2,575.46 | $4,343.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $789.75 / $1,307.47 / $2,828.25
| Professional | | $789.75 | $1,307.47 | $2,828.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,140.75 / $4,866.43 / $10,073.51
| Facility | | $1,140.75 | $4,866.43 | $10,073.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.34 / $2,759.74 / $4,334.85
| Professional | | $1,556.34 | $2,759.74 | $4,334.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.30 / $1,053.00 / $3,079.85
| Professional | | $807.30 | $1,053.00 | $3,079.85 |