- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $8,511.38
| Facility | | $1,148.15 | $1,148.15 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,148.15 / $1,819.70
| Professional | | $1,071.52 | $1,148.15 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,570.40 / $3,019.95
| Professional | | $2,089.30 | $2,570.40 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,187.76 / $3,548.13
| Professional | | $1,348.96 | $2,187.76 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,548.82 / $2,344.23
| Facility | | $1,148.15 | $1,548.82 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,089.30 / $8,511.38
| Professional | | $1,230.27 | $2,089.30 | $8,511.38 |
- 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
- $1,230.27 / $2,089.30 / $2,818.38
| Professional | | $1,230.27 | $2,089.30 | $2,818.38 |