- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,068.86 / $2,511.84 / $4,115.14
| Facility | | $1,068.86 | $2,511.84 | $4,115.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.26 / $1,068.86 / $1,135.68
| Professional | | $935.26 | $1,068.86 | $1,135.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.20 / $853.02 / $1,950.69
| Professional | | $699.20 | $853.02 | $1,950.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,336.09 / $3,908.06 / $38,413.74
| Facility | | $1,336.09 | $3,908.06 | $38,413.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.86 / $3,206.62 / $31,429.43
| Professional | | $1,396.86 | $3,206.62 | $31,429.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,519.81 / $2,813.81 / $9,007.75
| Facility | | $1,519.81 | $2,813.81 | $9,007.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,519.81 / $2,813.81 / $9,007.75
| Facility | | $1,519.81 | $2,813.81 | $9,007.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.16 / $801.65 / $1,764.57
| Professional | | $561.16 | $801.65 | $1,764.57 |