- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $8,511.38
| Facility | | $1,202.26 | $1,202.26 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,202.26 / $3,019.95
| Professional | | $1,096.48 | $1,202.26 | $3,019.95 |
- 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
- $1,258.93 / $2,290.87 / $3,801.89
| Professional | | $1,258.93 | $2,290.87 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,513.56 / $3,090.30
| Facility | | $1,148.15 | $1,513.56 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,187.76 / $3,090.30
| Professional | | $1,230.27 | $2,187.76 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,677.35 / $5,128.61
| Facility | | $3,090.30 | $4,677.35 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,137.96 / $2,884.03
| Professional | | $1,230.27 | $2,137.96 | $2,884.03 |