- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $2,691.53
| Facility | | $1,047.13 | $1,348.96 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,380.38 / $2,290.87
| Professional | | $1,047.13 | $1,380.38 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,513.56 / $5,754.40
| Facility | | $1,096.48 | $1,513.56 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,479.11 / $3,235.94
| Professional | | $1,380.38 | $1,479.11 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $10,232.93
| Facility | | $1,778.28 | $1,778.28 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,981.07
| Professional | | $1,288.25 | $1,288.25 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,819.70 / $3,311.31
| Facility | | $1,412.54 | $1,819.70 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,348.96 / $2,041.74
| Professional | | $1,000.00 | $1,348.96 | $2,041.74 |