- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,548.82 / $2,630.27
| Facility | | $1,288.25 | $1,548.82 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,548.82 / $2,570.40
| Professional | | $1,288.25 | $1,548.82 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,659.59 / $6,025.60
| Facility | | $1,230.27 | $1,659.59 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,659.59 / $3,630.78
| Professional | | $1,584.89 | $1,659.59 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $12,022.64
| Facility | | $1,949.84 | $1,949.84 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $4,365.16
| Professional | | $1,412.54 | $1,412.54 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,089.30 / $3,630.78
| Facility | | $1,318.26 | $2,089.30 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $2,290.87
| Professional | | $1,122.02 | $1,513.56 | $2,290.87 |