- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,380.38 / $3,388.44
| Facility | | $1,096.48 | $1,380.38 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,630.27
| Professional | | $1,096.48 | $1,445.44 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,023.29
| Facility | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $3,311.31 / $3,311.31
| Professional | | $977.24 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $776.25 / $6,456.54
| Facility | | $691.83 | $776.25 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,290.87 / $3,388.44
| Professional | | $1,548.82 | $2,290.87 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $3,890.45 / $8,709.64
| Facility | | $977.24 | $3,890.45 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,737.80 / $3,630.78
| Professional | | $1,174.90 | $1,737.80 | $3,630.78 |