- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $8,511.38
| Facility | | $1,202.26 | $1,202.26 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,202.26 / $3,235.94
| Professional | | $1,122.02 | $1,202.26 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,691.53 / $3,235.94
| Professional | | $2,187.76 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,290.87 / $3,801.89
| Professional | | $1,288.25 | $2,290.87 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,584.89 / $3,630.78
| Facility | | $1,202.26 | $1,584.89 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,187.76 / $9,332.54
| Professional | | $1,288.25 | $2,187.76 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $12,022.64 / $24,547.09
| Facility | | $10,715.19 | $12,022.64 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,187.76 / $2,951.21
| Professional | | $1,288.25 | $2,187.76 | $2,951.21 |