- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,862.09 / $2,398.83
| Facility | | $1,258.93 | $1,862.09 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,659.59 / $2,818.38
| Professional | | $741.31 | $1,659.59 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,079.46 / $9,772.37
| Facility | | $4,365.16 | $7,079.46 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,659.59 / $2,818.38
| Professional | | $1,023.29 | $1,659.59 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,659.59 / $4,073.80
| Professional | | $741.31 | $1,659.59 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,365.16 / $6,918.31
| Facility | | $1,479.11 | $4,365.16 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,445.44 / $2,754.23
| Professional | | $645.65 | $1,445.44 | $2,754.23 |