- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,230.27 / $8,511.38
| Facility | | $1,122.02 | $1,230.27 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,318.26 / $2,951.21
| Professional | | $1,122.02 | $1,318.26 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,754.23 / $3,235.94
| Professional | | $2,290.87 | $2,754.23 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,238.72 / $3,467.37
| Professional | | $1,318.26 | $2,238.72 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $3,630.78
| Facility | | $1,230.27 | $1,737.80 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,949.84 / $9,120.11
| Professional | | $1,148.15 | $1,949.84 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $10,715.19 / $20,417.38
| Facility | | $2,570.40 | $10,715.19 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,698.24 / $2,691.53
| Professional | | $1,122.02 | $1,698.24 | $2,691.53 |