- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,398.83
| Facility | | $1,096.48 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,047.13 / $1,905.46
| Professional | | $870.96 | $1,047.13 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,623.41 / $7,585.78
| Facility | | $4,677.35 | $5,623.41 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,348.96 / $1,584.89
| Professional | | $891.25 | $1,348.96 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $2,187.76
| Professional | | $812.83 | $1,148.15 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,248.07 / $8,709.64
| Facility | | $1,698.24 | $5,248.07 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,000.00 / $1,659.59
| Professional | | $741.31 | $1,000.00 | $1,659.59 |