- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,819.70 / $3,467.37
| Facility | | $1,122.02 | $1,819.70 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $912.01 / $1,023.29
| Professional | | $812.83 | $912.01 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $7,413.10
| Facility | | $5,370.32 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $1,230.27
| Professional | | $912.01 | $912.01 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,412.54 / $1,659.59
| Professional | | $676.08 | $1,412.54 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,981.07 / $11,748.98
| Facility | | $1,548.82 | $3,981.07 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $933.25 / $1,737.80
| Professional | | $758.58 | $933.25 | $1,737.80 |