- 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
- $457.09 / $588.84 / $1,000.00
| Professional | | $457.09 | $588.84 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,888.44 / $8,128.31
| Facility | | $4,786.30 | $5,888.44 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $707.95 / $831.76
| Professional | | $489.78 | $707.95 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $660.69 / $812.83
| Professional | | $457.09 | $660.69 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,659.59 / $5,248.07
| Facility | | $660.69 | $1,659.59 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $512.86 / $758.58
| Professional | | $354.81 | $512.86 | $758.58 |