- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $2,137.96
| Facility | | $1,318.26 | $1,318.26 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,023.29 / $2,951.21
| Professional | | $912.01 | $1,023.29 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $851.14 / $1,148.15
| Professional | | $524.81 | $851.14 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,862.09
| Professional | | $1,513.56 | $1,513.56 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,318.26 / $1,584.89
| Professional | | $776.25 | $1,318.26 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,258.93 / $2,951.21
| Professional | | $912.01 | $1,258.93 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $776.25 / $1,905.46
| Professional | | $660.69 | $776.25 | $1,905.46 |