- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $1,905.46
| Facility | | $933.25 | $1,122.02 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $1,862.09
| Professional | | $933.25 | $1,122.02 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $4,365.16
| Facility | | $891.25 | $1,230.27 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,318.26 / $2,570.40
| Professional | | $1,174.90 | $1,318.26 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $8,709.64
| Facility | | $1,230.27 | $1,230.27 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $3,162.28
| Professional | | $891.25 | $891.25 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,513.56 / $2,691.53
| Facility | | $977.24 | $1,513.56 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $1,659.59
| Professional | | $812.83 | $1,096.48 | $1,659.59 |