- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,126.89 / $2,817.23 / $12,161.90
| Facility | | $1,126.89 | $2,817.23 | $12,161.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.89 / $1,658.44 / $1,807.27
| Professional | | $1,126.89 | $1,658.44 | $1,807.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,078.36 / $3,140.75 / $6,694.67
| Facility | | $2,078.36 | $3,140.75 | $6,694.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,488.34 / $2,785.32 / $3,873.94
| Professional | | $1,488.34 | $2,785.32 | $3,873.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,488.34 / $1,488.34 / $12,381.00
| Facility | | $1,488.34 | $1,488.34 | $12,381.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,488.34 / $1,488.34 / $1,488.34
| Professional | | $1,488.34 | $1,488.34 | $1,488.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,657.75 / $2,657.75 / $2,657.75
| Facility | | $2,657.75 | $2,657.75 | $2,657.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.35 / $1,275.72 / $2,168.71
| Professional | | $882.35 | $1,275.72 | $2,168.71 |