- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,318.26 / $8,511.38
| Facility | | $1,288.25 | $1,318.26 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,318.26 / $2,137.96
| Professional | | $1,023.29 | $1,318.26 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,818.38 / $3,311.31
| Professional | | $2,290.87 | $2,818.38 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,187.76 / $3,630.78
| Professional | | $1,737.80 | $2,187.76 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,737.80 / $3,801.89
| Facility | | $1,288.25 | $1,737.80 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,630.27 / $3,019.95
| Professional | | $1,380.38 | $2,630.27 | $3,019.95 |
- 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
- $1,380.38 / $2,454.71 / $3,162.28
| Professional | | $1,380.38 | $2,454.71 | $3,162.28 |