- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,506.13 / $2,208.98 / $10,869.20
| Facility | | $1,506.13 | $2,208.98 | $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
- $1,530.54 / $2,142.73 / $9,438.95
| Facility | | $1,530.54 | $2,142.73 | $9,438.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,231.30 / $3,057.46 / $3,663.18
| Professional | | $2,231.30 | $3,057.46 | $3,663.18 |
- 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
- $2,789.12 / $2,789.12 / $4,183.68
| Facility | | $2,789.12 | $2,789.12 | $4,183.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.57 / $1,171.43 / $3,933.15
| Professional | | $878.57 | $1,171.43 | $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 |