- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,819.70 / $2,818.38
| Facility | | $1,288.25 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,096.48 / $1,318.26
| Professional | | $912.01 | $1,096.48 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $7,244.36
| Facility | | $5,248.07 | $5,248.07 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $1,288.25
| Professional | | $977.24 | $977.24 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Facility | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,548.82 / $1,819.70
| Professional | | $724.44 | $1,548.82 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,495.41 / $12,302.69
| Facility | | $2,089.30 | $5,495.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,023.29 / $1,819.70
| Professional | | $870.96 | $1,023.29 | $1,819.70 |