- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,238.72 / $2,570.40
| Facility | | $1,288.25 | $2,238.72 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,122.02 / $1,548.82
| Professional | | $870.96 | $1,122.02 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $812.83 / $2,137.96
| Professional | | $426.58 | $812.83 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,570.40 / $3,162.28
| Facility | | $1,737.80 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Professional | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,621.81 / $6,309.57
| Facility | | $1,174.90 | $1,621.81 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $794.33 / $6,606.93
| Professional | | $562.34 | $794.33 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $1,348.96 / $1,621.81
| Facility | | $562.34 | $1,348.96 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $794.33 / $1,479.11
| Professional | | $562.34 | $794.33 | $1,479.11 |