- 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
- $537.03 / $645.65 / $1,230.27
| Professional | | $537.03 | $645.65 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,248.07 / $7,079.46
| Facility | | $4,466.84 | $5,248.07 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $812.83 / $933.25
| Professional | | $537.03 | $812.83 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $741.31 / $1,445.44
| Professional | | $512.86 | $741.31 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,659.59 / $3,090.30
| Facility | | $630.96 | $1,659.59 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $630.96 / $1,000.00
| Professional | | $457.09 | $630.96 | $1,000.00 |