- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,513.56 / $2,398.83
| Facility | | $1,023.29 | $1,513.56 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $1,621.81 / $4,168.69
| Professional | | $457.09 | $1,621.81 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,370.32 / $7,244.36
| Facility | | $4,466.84 | $5,370.32 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $1,698.24 / $2,511.89
| Professional | | $436.52 | $1,698.24 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Facility | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $1,513.56 / $3,801.89
| Professional | | $338.84 | $1,513.56 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,168.69 / $6,309.57
| Facility | | $1,202.26 | $4,168.69 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $1,659.59 / $2,818.38
| Professional | | $363.08 | $1,659.59 | $2,818.38 |