- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $2,398.83
| Facility | | $1,096.48 | $1,659.59 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,096.48 / $1,621.81
| Professional | | $794.33 | $1,096.48 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,818.38 / $3,801.89
| Facility | | $2,344.23 | $2,818.38 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,000.00 / $1,949.84
| Professional | | $707.95 | $1,000.00 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Facility | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $851.14 / $2,951.21
| Professional | | $588.84 | $851.14 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,951.21 / $4,365.16
| Facility | | $831.76 | $2,951.21 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $812.83 / $1,071.52
| Professional | | $691.83 | $812.83 | $1,071.52 |