- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $3,981.07
| Facility | | $1,047.13 | $1,479.11 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,412.54 / $2,454.71
| Professional | | $1,023.29 | $1,412.54 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,412.54 / $5,128.61
| Facility | | $1,047.13 | $1,412.54 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,778.28 / $3,311.31
| Professional | | $1,380.38 | $1,778.28 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,819.70 / $11,220.18
| Facility | | $1,778.28 | $1,819.70 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $4,265.80
| Professional | | $1,318.26 | $1,318.26 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $1,698.24 / $3,090.30
| Facility | | $954.99 | $1,698.24 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,380.38 / $1,949.84
| Professional | | $954.99 | $1,380.38 | $1,949.84 |