- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,621.81 / $2,137.96
| Facility | | $1,230.27 | $1,621.81 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,137.96
| Professional | | $933.25 | $1,318.26 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $4,897.79
| Facility | | $3,548.13 | $3,548.13 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,698.24
| Professional | | $1,288.25 | $1,288.25 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,445.44 / $2,137.96
| Professional | | $891.25 | $1,445.44 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,818.38 / $8,128.31
| Facility | | $1,230.27 | $2,818.38 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,202.26 / $2,187.76
| Professional | | $954.99 | $1,202.26 | $2,187.76 |