- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,890.45 / $7,943.28
| Facility | | $2,041.74 | $3,890.45 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $3,235.94 / $4,677.35
| Professional | | $870.96 | $3,235.94 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,235.94 / $5,888.44
| Facility | | $1,230.27 | $3,235.94 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,659.59 / $2,691.53
| Professional | | $1,288.25 | $1,659.59 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $1,513.56 / $3,235.94
| Facility | | $524.81 | $1,513.56 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Professional | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,348.96 / $3,235.94
| Facility | | $602.56 | $1,348.96 | $3,235.94 |