- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,412.54 / $8,511.38
| Facility | | $1,380.38 | $1,412.54 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,412.54 / $2,290.87
| Professional | | $1,096.48 | $1,412.54 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,019.95 / $3,630.78
| Professional | | $2,454.71 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,344.23 / $3,981.07
| Professional | | $1,905.46 | $2,344.23 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,862.09 / $4,168.69
| Facility | | $1,380.38 | $1,862.09 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,884.03 / $3,235.94
| Professional | | $1,513.56 | $2,884.03 | $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
- $1,513.56 / $2,691.53 / $3,467.37
| Professional | | $1,513.56 | $2,691.53 | $3,467.37 |