- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,506.13 / $1,882.66 / $10,869.20
| Facility | | $1,506.13 | $1,882.66 | $10,869.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.13 / $1,706.94 / $2,259.19
| Professional | | $1,506.13 | $1,706.94 | $2,259.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,261.10 / $1,765.56 / $9,438.95
| Facility | | $1,261.10 | $1,765.56 | $9,438.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,776.14 / $2,776.14 / $3,326.13
| Professional | | $2,776.14 | $2,776.14 | $3,326.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.13 / $1,506.13 / $2,133.67
| Professional | | $1,506.13 | $1,506.13 | $2,133.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,510.21 / $3,765.32
| Facility | | $2,510.21 | $2,510.21 | $3,765.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.57 / $1,054.29 / $3,933.15
| Professional | | $878.57 | $1,054.29 | $3,933.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.13 / $1,506.13 / $1,506.13
| Professional | | $1,506.13 | $1,506.13 | $1,506.13 |