- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,621.81 / $2,041.74
| Facility | | $1,047.13 | $1,621.81 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $891.25 / $1,023.29
| Professional | | $776.25 | $891.25 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $3,630.78
| Facility | | $2,630.27 | $2,630.27 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $1,230.27
| Professional | | $933.25 | $933.25 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,047.13 / $1,445.44
| Professional | | $575.44 | $1,047.13 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,137.96 / $7,079.46
| Facility | | $977.24 | $2,137.96 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,023.29 / $1,479.11
| Professional | | $741.31 | $1,023.29 | $1,479.11 |