- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,479.11 / $2,511.89
| Facility | | $1,174.90 | $1,479.11 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,479.11 / $2,454.71
| Professional | | $1,174.90 | $1,479.11 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $5,623.41
| Facility | | $1,122.02 | $1,513.56 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,513.56 / $3,311.31
| Professional | | $1,479.11 | $1,513.56 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $11,481.54
| Facility | | $1,949.84 | $1,949.84 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $4,365.16
| Professional | | $1,445.44 | $1,445.44 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,862.09 / $3,311.31
| Facility | | $1,096.48 | $1,862.09 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,412.54 / $2,137.96
| Professional | | $1,000.00 | $1,412.54 | $2,137.96 |