- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,255.35 / $1,856.89 / $1,916.36
| Facility | | $1,255.35 | $1,856.89 | $1,916.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.35 / $1,438.44 / $2,615.34
| Professional | | $1,255.35 | $1,438.44 | $2,615.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.74 / $2,885.13 / $12,683.57
| Facility | | $2,747.74 | $2,885.13 | $12,683.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.05 / $1,487.71 / $2,224.09
| Professional | | $1,373.05 | $1,487.71 | $2,224.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.24 / $1,786.24 / $1,786.24
| Facility | | $1,786.24 | $1,786.24 | $1,786.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.96 / $1,303.96 / $1,839.83
| Professional | | $1,303.96 | $1,303.96 | $1,839.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,255.35 / $2,301.50 / $12,858.35
| Facility | | $1,255.35 | $2,301.50 | $12,858.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.52 / $1,468.77 / $2,220.77
| Professional | | $1,025.52 | $1,468.77 | $2,220.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.52 / $1,370.82 / $1,945.81
| Professional | | $1,025.52 | $1,370.82 | $1,945.81 |