- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,412.54 / $8,511.38
| Facility | | $1,380.38 | $1,412.54 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,412.54 / $3,311.31
| Professional | | $1,288.25 | $1,412.54 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,019.95 / $3,630.78
| Professional | | $2,454.71 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,630.27 / $4,265.80
| Professional | | $1,479.11 | $2,630.27 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,778.28 / $3,019.95
| Facility | | $1,380.38 | $1,778.28 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,511.89 / $11,481.54
| Professional | | $1,445.44 | $2,511.89 | $11,481.54 |
- 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
- $1,445.44 / $2,454.71 / $3,311.31
| Professional | | $1,445.44 | $2,454.71 | $3,311.31 |