- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $8,511.38
| Facility | | $1,047.13 | $1,047.13 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,047.13 / $2,630.27
| Professional | | $954.99 | $1,047.13 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,344.23 / $2,754.23
| Professional | | $1,862.09 | $2,344.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,995.26 / $3,235.94
| Professional | | $1,288.25 | $1,995.26 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,412.54 / $3,162.28
| Facility | | $1,047.13 | $1,412.54 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,862.09 / $7,762.47
| Professional | | $1,096.48 | $1,862.09 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,128.61 / $24,547.09
| Facility | | $4,677.35 | $5,128.61 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,862.09 / $2,511.89
| Professional | | $1,096.48 | $1,862.09 | $2,511.89 |