- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $3,090.30 / $4,365.16
| Facility | | $1,412.54 | $3,090.30 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,412.54 / $1,548.82
| Professional | | $977.24 | $1,412.54 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,137.96
| Professional | | $1,995.26 | $1,995.26 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,041.74 / $3,801.89
| Facility | | $1,905.46 | $2,041.74 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,137.96 / $10,715.19
| Professional | | $1,445.44 | $2,137.96 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Professional | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,290.87 / $3,890.45
| Professional | | $1,513.56 | $2,290.87 | $3,890.45 |