- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,778.28 / $2,398.83
| Facility | | $1,202.26 | $1,778.28 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $3,019.95 / $8,709.64
| Professional | | $776.25 | $3,019.95 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $7,079.46 / $9,549.93
| Facility | | $5,888.44 | $7,079.46 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $4,570.88 / $7,762.47
| Professional | | $776.25 | $4,570.88 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,445.44 / $10,964.78
| Professional | | $707.95 | $1,445.44 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $7,244.36 / $12,022.64
| Facility | | $3,388.44 | $7,244.36 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,348.96 / $7,413.10
| Professional | | $630.96 | $1,348.96 | $7,413.10 |