- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,698.24 / $2,454.71
| Facility | | $1,148.15 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,023.29 / $1,584.89
| Professional | | $891.25 | $1,023.29 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $4,168.69
| Facility | | $3,019.95 | $3,019.95 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,412.54
| Professional | | $1,047.13 | $1,047.13 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Facility | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,445.44 / $1,698.24
| Professional | | $831.76 | $1,445.44 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,890.45 / $7,762.47
| Facility | | $1,548.82 | $3,890.45 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,148.15 / $1,862.09
| Professional | | $891.25 | $1,148.15 | $1,862.09 |