- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,366.07 / $1,366.07 / $1,653.82
| Facility | | $1,366.07 | $1,366.07 | $1,653.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.90 / $1,366.07 / $1,653.82
| Professional | | $1,312.90 | $1,366.07 | $1,653.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,085.68 / $1,085.68 / $1,085.68
| Facility | | $1,085.68 | $1,085.68 | $1,085.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,398.64 / $2,015.63 / $2,943.80
| Professional | | $1,398.64 | $2,015.63 | $2,943.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,366.07 / $2,111.73 / $6,026.00
| Facility | | $1,366.07 | $2,111.73 | $6,026.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.72 / $2,002.38 / $11,810.40
| Professional | | $1,461.72 | $2,002.38 | $11,810.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,481.00 / $5,524.00 / $9,232.95
| Facility | | $1,481.00 | $5,524.00 | $9,232.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.96 / $1,828.26 / $2,481.21
| Professional | | $1,392.96 | $1,828.26 | $2,481.21 |