- 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 / $1,445.44 / $2,884.03
| Professional | | $1,202.26 | $1,445.44 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,884.03 / $3,467.37
| Professional | | $2,454.71 | $2,884.03 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,398.83 / $3,630.78
| Professional | | $1,380.38 | $2,398.83 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,819.70 / $2,818.38
| Facility | | $1,318.26 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,137.96 / $9,549.93
| Professional | | $1,202.26 | $2,137.96 | $9,549.93 |
- 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
- $1,174.90 / $1,819.70 / $2,818.38
| Professional | | $1,174.90 | $1,819.70 | $2,818.38 |