- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,445.44 / $8,511.38
| Facility | | $1,380.38 | $1,445.44 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,445.44 / $2,344.23
| Professional | | $933.25 | $1,445.44 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,884.03 / $3,548.13
| Professional | | $2,454.71 | $2,884.03 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,398.83 / $3,981.07
| Professional | | $1,905.46 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,905.46 / $4,168.69
| Facility | | $1,380.38 | $1,905.46 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,511.89 / $3,235.94
| Professional | | $1,445.44 | $2,511.89 | $3,235.94 |
- 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 / $2,630.27 / $3,467.37
| Professional | | $1,445.44 | $2,630.27 | $3,467.37 |