- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,995.26 / $4,466.84
| Facility | | $1,096.48 | $1,995.26 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,230.27 / $3,162.28
| Professional | | $1,096.48 | $1,230.27 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,318.26 / $2,238.72
| Professional | | $977.24 | $1,318.26 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $4,168.69 / $10,715.19
| Facility | | $977.24 | $4,168.69 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,318.26 / $2,570.40
| Professional | | $977.24 | $1,318.26 | $2,570.40 |