- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $8,511.38
| Facility | | $1,513.56 | $1,548.82 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,548.82 / $2,570.40
| Professional | | $1,071.52 | $1,548.82 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,311.31 / $3,981.07
| Professional | | $2,691.53 | $3,311.31 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,570.40 / $4,365.16
| Professional | | $2,089.30 | $2,570.40 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,089.30 / $4,570.88
| Facility | | $1,513.56 | $2,089.30 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,884.03 / $3,548.13
| Professional | | $1,659.59 | $2,884.03 | $3,548.13 |
- 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
- $1,659.59 / $2,884.03 / $3,801.89
| Professional | | $1,659.59 | $2,884.03 | $3,801.89 |