- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,318.26 / $8,511.38
| Facility | | $1,202.26 | $1,318.26 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,479.11 / $2,754.23
| Professional | | $1,202.26 | $1,479.11 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,951.21 / $3,548.13
| Professional | | $2,511.89 | $2,951.21 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,454.71 / $3,715.35
| Professional | | $1,412.54 | $2,454.71 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,862.09 / $2,818.38
| Facility | | $1,318.26 | $1,862.09 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,137.96 / $9,772.37
| Professional | | $1,230.27 | $2,137.96 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,819.70 / $2,041.74
| Facility | | $676.08 | $1,819.70 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,819.70 / $2,884.03
| Professional | | $1,202.26 | $1,819.70 | $2,884.03 |