- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,630.78 / $4,786.30
| Facility | | $3,162.28 | $3,630.78 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $2,344.23 / $3,630.78
| Professional | | $478.63 | $2,344.23 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $891.25
| Facility | | $549.54 | $660.69 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,041.74 / $2,570.40
| Professional | | $1,737.80 | $2,041.74 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,570.40 / $6,760.83
| Facility | | $1,995.26 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,818.38 / $3,162.28
| Facility | | $1,318.26 | $2,818.38 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,905.46
| Professional | | $1,318.26 | $1,318.26 | $1,905.46 |