- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,098.92 / $1,753.62 / $3,641.63
| Facility | | $1,098.92 | $1,753.62 | $3,641.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.26 / $1,082.23 / $1,202.48
| Professional | | $935.26 | $1,082.23 | $1,202.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,103.10 / $1,960.71 / $5,828.96
| Facility | | $1,103.10 | $1,960.71 | $5,828.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.20 / $699.20 / $1,666.52
| Professional | | $699.20 | $699.20 | $1,666.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,113.80 / $2,247.14 / $4,154.93
| Facility | | $1,113.80 | $2,247.14 | $4,154.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,603.31 / $1,628.46 / $2,035.58
| Professional | | $1,603.31 | $1,628.46 | $2,035.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,004.14 / $2,004.14 / $2,004.14
| Facility | | $2,004.14 | $2,004.14 | $2,004.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.16 / $801.65 / $1,603.31
| Professional | | $561.16 | $801.65 | $1,603.31 |