- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $2,041.74
| Facility | | $1,148.15 | $1,621.81 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,047.13 / $1,621.81
| Professional | | $912.01 | $1,047.13 | $1,621.81 |
- 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
- $1,071.52 / $1,071.52 / $1,412.54
| Professional | | $1,071.52 | $1,071.52 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,445.44 / $1,737.80
| Professional | | $851.14 | $1,445.44 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,445.44 / $5,248.07
| Facility | | $588.84 | $1,445.44 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,174.90 / $1,862.09
| Professional | | $912.01 | $1,174.90 | $1,862.09 |