- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,445.44 / $8,511.38
| Facility | | $1,412.54 | $1,445.44 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,454.71
| Professional | | $1,096.48 | $1,445.44 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,090.30 / $3,715.35
| Professional | | $2,570.40 | $3,090.30 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $4,570.88
| Professional | | $1,862.09 | $2,630.27 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,290.87 / $4,265.80
| Facility | | $1,412.54 | $2,290.87 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,570.40 / $3,090.30
| Professional | | $1,445.44 | $2,570.40 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,570.40 / $3,548.13
| Professional | | $1,445.44 | $2,570.40 | $3,548.13 |