- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,824.88 / $2,098.61 / $3,649.76
| Facility | | $1,824.88 | $2,098.61 | $3,649.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,423.41 / $2,098.61 / $2,098.61
| Professional | | $1,423.41 | $2,098.61 | $2,098.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.89 / $652.76 / $878.17
| Facility | | $537.89 | $652.76 | $878.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.70 / $1,864.40 / $2,199.98
| Professional | | $1,268.70 | $1,864.40 | $2,199.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,435.27 / $1,692.85 / $3,949.95
| Facility | | $1,435.27 | $1,692.85 | $3,949.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.05 / $1,101.25 / $10,180.65
| Professional | | $806.05 | $1,101.25 | $10,180.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.45 / $766.45 / $1,491.52
| Professional | | $766.45 | $766.45 | $1,491.52 |