- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,949.84 / $2,818.38
| Facility | | $1,318.26 | $1,949.84 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,041.74 / $2,754.23
| Professional | | $1,318.26 | $2,041.74 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $316.23 / $1,479.11
| Facility | | $251.19 | $316.23 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,995.26 / $4,265.80
| Professional | | $1,479.11 | $1,995.26 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $4,570.88 / $12,589.25
| Facility | | $812.83 | $4,570.88 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,884.03 / $3,715.35
| Professional | | $1,479.11 | $2,884.03 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $295.12 / $2,511.89
| Facility | | $138.04 | $295.12 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $416.87 / $2,570.40
| Professional | | $144.54 | $416.87 | $2,570.40 |