- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,584.89 / $2,290.87
| Facility | | $794.33 | $1,584.89 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,318.26 / $1,819.70
| Professional | | $1,174.90 | $1,318.26 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $8,511.38
| Facility | | $6,309.57 | $6,309.57 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,905.46
| Professional | | $1,445.44 | $1,445.44 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,905.46 / $2,754.23
| Professional | | $1,071.52 | $1,905.46 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,981.07 / $12,589.25
| Facility | | $1,548.82 | $3,981.07 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,513.56 / $2,398.83
| Professional | | $1,148.15 | $1,513.56 | $2,398.83 |