- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,621.81 / $2,041.74
| Facility | | $1,096.48 | $1,621.81 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,096.48 / $1,698.24
| Professional | | $758.58 | $1,096.48 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $3,019.95
| Facility | | $2,187.76 | $2,187.76 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,380.38
| Professional | | $1,047.13 | $1,047.13 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $588.84 / $588.84
| Facility | | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,174.90 / $1,778.28
| Professional | | $724.44 | $1,174.90 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $363.08 / $3,019.95
| Facility | | $128.82 | $363.08 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $1,778.28
| Professional | | $812.83 | $1,000.00 | $1,778.28 |