- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $8,511.38
| Facility | | $1,071.52 | $1,071.52 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,071.52 / $2,630.27
| Professional | | $933.25 | $1,071.52 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,511.89 / $3,019.95
| Professional | | $2,041.74 | $2,511.89 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,041.74 / $3,388.44
| Professional | | $1,096.48 | $2,041.74 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,412.54 / $1,862.09
| Facility | | $1,071.52 | $1,412.54 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,905.46 / $8,128.31
| Professional | | $1,071.52 | $1,905.46 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $14,125.38
| Facility | | $1,819.70 | $2,041.74 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,995.26 / $2,691.53
| Professional | | $1,071.52 | $1,995.26 | $2,691.53 |