- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,513.56 / $8,511.38
| Facility | | $1,318.26 | $1,513.56 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $2,137.96
| Professional | | $1,258.93 | $1,513.56 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,951.21 / $3,467.37
| Professional | | $2,398.83 | $2,951.21 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,570.40 / $4,265.80
| Professional | | $1,202.26 | $2,570.40 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,949.84 / $3,162.28
| Facility | | $1,318.26 | $1,949.84 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,238.72 / $11,220.18
| Professional | | $1,122.02 | $2,238.72 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,801.89 / $5,888.44
| Facility | | $3,235.94 | $3,801.89 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,238.72 / $3,090.30
| Professional | | $1,202.26 | $2,238.72 | $3,090.30 |