- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,047.13 / $1,949.84
| Facility | | $812.83 | $1,047.13 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,047.13 / $1,737.80
| Professional | | $776.25 | $1,047.13 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,122.02 / $4,265.80
| Facility | | $831.76 | $1,122.02 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,096.48 / $2,454.71
| Professional | | $1,047.13 | $1,096.48 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $7,762.47
| Facility | | $1,348.96 | $1,348.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $3,019.95
| Professional | | $977.24 | $977.24 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,348.96 / $2,454.71
| Facility | | $1,000.00 | $1,348.96 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,047.13 / $1,548.82
| Professional | | $758.58 | $1,047.13 | $1,548.82 |