- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.72 / $1,594.65 / $9,206.45
| Facility | | $1,275.72 | $1,594.65 | $9,206.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.72 / $1,424.55 / $1,913.58
| Professional | | $1,275.72 | $1,424.55 | $1,913.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,067.83 / $1,494.97 / $7,994.08
| Facility | | $1,067.83 | $1,494.97 | $7,994.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,589.91 / $2,589.91 / $3,103.00
| Professional | | $2,589.91 | $2,589.91 | $3,103.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.72 / $1,275.72 / $1,807.27
| Professional | | $1,275.72 | $1,275.72 | $1,807.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.19 / $2,126.19 / $3,189.30
| Facility | | $2,126.19 | $2,126.19 | $3,189.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $744.17 / $893.00 / $3,189.30
| Professional | | $744.17 | $893.00 | $3,189.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.72 / $1,275.72 / $1,275.72
| Professional | | $1,275.72 | $1,275.72 | $1,275.72 |