- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $8,511.38
| Facility | | $1,230.27 | $1,230.27 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,202.26 / $2,884.03
| Professional | | $1,096.48 | $1,202.26 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,691.53 / $3,235.94
| Professional | | $2,187.76 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,344.23 / $3,801.89
| Professional | | $1,230.27 | $2,344.23 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,513.56 / $3,715.35
| Facility | | $1,230.27 | $1,513.56 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,187.76 / $14,791.08
| Professional | | $1,258.93 | $2,187.76 | $14,791.08 |
- 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
- $1,258.93 / $2,187.76 / $3,019.95
| Professional | | $1,258.93 | $2,187.76 | $3,019.95 |