- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,467.37 / $6,760.83
| Facility | | $1,047.13 | $3,467.37 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,047.13 / $1,737.80
| Professional | | $870.96 | $1,047.13 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,230.27 / $1,445.44
| Professional | | $933.25 | $1,230.27 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,862.09 / $5,888.44
| Facility | | $933.25 | $1,862.09 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $7,079.46
| Professional | | $812.83 | $1,096.48 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,951.21 / $5,888.44
| Facility | | $891.25 | $2,951.21 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $1,445.44
| Professional | | $776.25 | $1,000.00 | $1,445.44 |