- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,412.54 / $8,511.38
| Facility | | $1,348.96 | $1,412.54 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,412.54 / $2,290.87
| Professional | | $912.01 | $1,412.54 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,019.95 / $3,548.13
| Professional | | $2,398.83 | $3,019.95 | $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
- $1,348.96 / $1,862.09 / $4,073.80
| Facility | | $1,348.96 | $1,862.09 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,511.89 / $3,162.28
| Professional | | $1,445.44 | $2,511.89 | $3,162.28 |
- 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 / $3,388.44
| Professional | | $1,445.44 | $2,570.40 | $3,388.44 |