- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,168.69 / $5,128.61
| Facility | | $1,445.44 | $4,168.69 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,258.93 / $3,090.30
| Professional | | $831.76 | $1,258.93 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $2,344.23
| Facility | | $1,230.27 | $1,230.27 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $6,606.93 / $6,606.93
| Professional | | $1,230.27 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,090.30 / $5,623.41
| Facility | | $2,238.72 | $3,090.30 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Professional | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,258.93 / $1,513.56
| Professional | | $1,202.26 | $1,258.93 | $1,513.56 |