- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $1,995.26 / $3,715.35
| Facility | | $426.58 | $1,995.26 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,479.11 / $3,311.31
| Professional | | $1,380.38 | $1,479.11 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Professional | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,258.93 / $1,905.46
| Facility | | $1,174.90 | $1,258.93 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,905.46 / $3,630.78
| Professional | | $831.76 | $1,905.46 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,819.70 / $2,511.89
| Facility | | $1,659.59 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,230.27 / $5,495.41
| Professional | | $758.58 | $1,230.27 | $5,495.41 |