- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,162.28 / $6,606.93
| Facility | | $1,122.02 | $3,162.28 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,023.29 / $1,819.70
| Professional | | $812.83 | $1,023.29 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,511.89 / $3,548.13
| Facility | | $1,047.13 | $2,511.89 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,148.15 / $2,137.96
| Professional | | $776.25 | $1,148.15 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,862.09 / $5,495.41
| Facility | | $933.25 | $1,862.09 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,479.11 / $2,570.40
| Professional | | $933.25 | $1,479.11 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,041.74 / $3,630.78
| Facility | | $977.24 | $2,041.74 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,202.26 / $2,137.96
| Professional | | $812.83 | $1,202.26 | $2,137.96 |