- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $2,630.27
| Facility | | $1,096.48 | $1,479.11 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $2,344.23
| Professional | | $1,096.48 | $1,479.11 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $6,025.60
| Facility | | $1,122.02 | $1,513.56 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $3,388.44
| Professional | | $1,479.11 | $1,479.11 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $11,220.18
| Facility | | $1,513.56 | $1,513.56 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $4,265.80
| Professional | | $1,122.02 | $1,122.02 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,819.70 / $3,311.31
| Facility | | $1,621.81 | $1,819.70 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $2,187.76
| Professional | | $1,023.29 | $1,445.44 | $2,187.76 |