- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,318.26 / $9,549.93
| Facility | | $1,230.27 | $1,318.26 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,318.26 / $1,862.09
| Professional | | $812.83 | $1,318.26 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,691.53 / $3,162.28
| Professional | | $2,187.76 | $2,691.53 | $3,162.28 |
- 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
- $1,230.27 / $1,737.80 / $3,715.35
| Facility | | $1,230.27 | $1,737.80 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,290.87 / $2,884.03
| Professional | | $1,202.26 | $2,290.87 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,128.61 / $5,128.61
| Facility | | $4,677.35 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,290.87 / $3,090.30
| Professional | | $1,202.26 | $2,290.87 | $3,090.30 |