- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,370.32 / $7,413.10
| Facility | | $1,995.26 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,412.54 / $2,754.23
| Professional | | $1,122.02 | $1,412.54 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,677.35 / $9,772.37
| Facility | | $1,995.26 | $4,677.35 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,819.70 / $2,454.71
| Professional | | $1,202.26 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,995.26 / $3,162.28
| Professional | | $1,122.02 | $1,995.26 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,348.96 / $2,398.83
| Professional | | $1,071.52 | $1,348.96 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,754.40 / $8,511.38
| Facility | | $1,513.56 | $5,754.40 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,659.59 / $3,019.95
| Professional | | $1,202.26 | $1,659.59 | $3,019.95 |