- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,288.25 / $1,778.28
| Facility | | $1,230.27 | $1,288.25 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,479.11
| Professional | | $1,230.27 | $1,230.27 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $120.23 / $1,548.82
| Professional | | $97.72 | $120.23 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $144.54 / $194.98
| Professional | | $123.03 | $144.54 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,230.27 / $1,230.27
| Facility | | $1,174.90 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,513.56 / $3,388.44
| Facility | | $1,202.26 | $1,513.56 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,202.26 / $5,128.61
| Professional | | $1,047.13 | $1,202.26 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,659.59
| Facility | | $1,412.54 | $1,412.54 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,047.13 / $1,412.54
| Professional | | $125.89 | $1,047.13 | $1,412.54 |