- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $898.71 / $898.71 / $6,374.41
| Facility | | $898.71 | $898.71 | $6,374.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.68 / $898.71 / $898.71
| Professional | | $817.68 | $898.71 | $898.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.36 / $1,030.70 / $1,123.46
| Professional | | $346.36 | $1,030.70 | $1,123.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,521.58 / $3,218.50 / $4,056.80
| Facility | | $2,521.58 | $3,218.50 | $4,056.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.70 / $1,416.87 / $4,021.78
| Professional | | $863.70 | $1,416.87 | $4,021.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.65 / $2,192.42 / $2,192.42
| Professional | | $1,081.65 | $2,192.42 | $2,192.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,577.52 / $2,684.51 / $2,980.43
| Facility | | $2,577.52 | $2,684.51 | $2,980.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.20 / $2,055.80 / $2,778.09
| Professional | | $762.20 | $2,055.80 | $2,778.09 |