- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,380.38 / $8,511.38
| Facility | | $1,348.96 | $1,380.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,380.38 / $2,290.87
| Professional | | $933.25 | $1,380.38 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,951.21 / $3,548.13
| Professional | | $2,398.83 | $2,951.21 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,290.87 / $3,890.45
| Professional | | $1,862.09 | $2,290.87 | $3,890.45 |
- 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
- $1,479.11 / $2,511.89 / $3,162.28
| Professional | | $1,479.11 | $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
- $1,479.11 / $2,511.89 / $3,388.44
| Professional | | $1,479.11 | $2,511.89 | $3,388.44 |