- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,862.09 / $2,398.83
| Facility | | $1,348.96 | $1,862.09 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,819.70 / $2,398.83
| Professional | | $1,174.90 | $1,819.70 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $5,754.40
| Facility | | $173.78 | $173.78 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,290.87 / $3,162.28
| Professional | | $1,318.26 | $2,290.87 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $3,090.30
| Facility | | $1,412.54 | $1,412.54 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,412.54 / $4,466.84
| Professional | | $1,202.26 | $1,412.54 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.49 / $912.01 / $1,737.80
| Facility | | $117.49 | $912.01 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,318.26 / $2,238.72
| Professional | | $912.01 | $1,318.26 | $2,238.72 |