- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,621.81 / $2,089.30
| Facility | | $1,230.27 | $1,621.81 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,230.27 / $1,862.09
| Professional | | $1,096.48 | $1,230.27 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,995.26
| Facility | | $1,445.44 | $1,445.44 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,698.24
| Professional | | $1,288.25 | $1,288.25 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Facility | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,778.28 / $2,089.30
| Professional | | $912.01 | $1,778.28 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,041.74 / $4,570.88
| Facility | | $977.24 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,348.96 / $2,187.76
| Professional | | $1,096.48 | $1,348.96 | $2,187.76 |