- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,513.56 / $8,511.38
| Facility | | $1,412.54 | $1,513.56 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,513.56 / $2,137.96
| Professional | | $954.99 | $1,513.56 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,818.38 / $3,388.44
| Professional | | $2,290.87 | $2,818.38 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,187.76 / $3,715.35
| Professional | | $1,778.28 | $2,187.76 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,737.80 / $4,265.80
| Facility | | $1,412.54 | $1,737.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,570.40 / $3,311.31
| Professional | | $1,445.44 | $2,570.40 | $3,311.31 |
- 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 |