- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $8,511.38
| Facility | | $1,584.89 | $1,584.89 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,548.82 / $2,398.83
| Professional | | $1,318.26 | $1,548.82 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,311.31 / $3,981.07
| Professional | | $2,691.53 | $3,311.31 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,951.21 / $4,897.79
| Professional | | $1,621.81 | $2,951.21 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,862.09 / $2,818.38
| Facility | | $1,584.89 | $1,862.09 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,884.03 / $13,803.84
| Professional | | $1,584.89 | $2,884.03 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $11,481.54
| Facility | | $1,819.70 | $2,041.74 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,818.38 / $3,715.35
| Professional | | $1,584.89 | $2,818.38 | $3,715.35 |