- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,621.81 / $2,041.74
| Facility | | $1,230.27 | $1,621.81 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,071.52 / $1,288.25
| Professional | | $851.14 | $1,071.52 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,570.40
| Facility | | $1,905.46 | $1,905.46 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $1,230.27
| Professional | | $933.25 | $933.25 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,513.56 / $1,737.80
| Professional | | $691.83 | $1,513.56 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,754.23 / $6,025.60
| Facility | | $1,230.27 | $2,754.23 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,000.00 / $1,862.09
| Professional | | $851.14 | $1,000.00 | $1,862.09 |