- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,659.59 / $3,548.13
| Facility | | $1,230.27 | $1,659.59 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,380.38 / $1,659.59
| Professional | | $1,230.27 | $1,380.38 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,715.35 / $4,365.16
| Professional | | $2,570.40 | $3,715.35 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,818.38
| Professional | | $2,238.72 | $2,238.72 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $3,548.13
| Facility | | $1,047.13 | $1,348.96 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $2,089.30 / $3,548.13
| Professional | | $741.31 | $2,089.30 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,949.84 / $2,951.21
| Professional | | $741.31 | $1,949.84 | $2,951.21 |