- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,317.12 / $1,948.25 / $2,010.64
| Facility | | $1,317.12 | $1,948.25 | $2,010.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.12 / $1,509.21 / $2,744.01
| Professional | | $1,317.12 | $1,509.21 | $2,744.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,882.92 / $3,027.07 / $13,307.56
| Facility | | $2,882.92 | $3,027.07 | $13,307.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.84 / $1,481.65 / $2,332.41
| Professional | | $1,406.84 | $1,481.65 | $2,332.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,769.38 / $1,769.38 / $1,769.38
| Facility | | $1,769.38 | $1,769.38 | $1,769.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.65 / $1,291.65 / $1,822.46
| Professional | | $1,291.65 | $1,291.65 | $1,822.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,317.12 / $2,323.40 / $12,904.54
| Facility | | $1,317.12 | $2,323.40 | $12,904.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.28 / $1,541.03 / $2,427.10
| Professional | | $1,008.28 | $1,541.03 | $2,427.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.28 / $1,438.26 / $2,041.54
| Professional | | $1,008.28 | $1,438.26 | $2,041.54 |