- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,584.89 / $2,041.74
| Facility | | $1,096.48 | $1,584.89 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $1,995.26
| Professional | | $1,047.13 | $1,479.11 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $4,897.79
| Facility | | $144.54 | $144.54 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $1,905.46 / $2,691.53
| Professional | | $316.23 | $1,905.46 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $2,238.72
| Facility | | $1,445.44 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,445.44 / $3,801.89
| Professional | | $1,230.27 | $1,445.44 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.33 / $776.25 / $1,479.11
| Facility | | $93.33 | $776.25 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,096.48 / $1,819.70
| Professional | | $776.25 | $1,096.48 | $1,819.70 |