- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,153.60 / $1,706.39 / $1,761.02
| Facility | | $1,153.60 | $1,706.39 | $1,761.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.60 / $1,507.41 / $2,403.36
| Professional | | $1,153.60 | $1,507.41 | $2,403.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,525.03 / $2,651.28 / $11,655.54
| Facility | | $2,525.03 | $2,651.28 | $11,655.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,398.52 / $1,526.81 / $2,076.90
| Professional | | $1,398.52 | $1,526.81 | $2,076.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,119.51 / $2,119.51 / $2,119.51
| Facility | | $2,119.51 | $2,119.51 | $2,119.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.24 / $1,547.24 / $2,183.10
| Professional | | $1,547.24 | $1,547.24 | $2,183.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,153.60 / $2,114.96 / $13,256.99
| Facility | | $1,153.60 | $2,114.96 | $13,256.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.82 / $1,371.23 / $2,559.11
| Professional | | $1,043.82 | $1,371.23 | $2,559.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.82 / $1,259.71 / $1,930.19
| Professional | | $1,043.82 | $1,259.71 | $1,930.19 |