- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,698.24 / $2,454.71
| Facility | | $1,348.96 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,122.02 / $1,698.24
| Professional | | $1,000.00 | $1,122.02 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $537.03 / $562.34
| Facility | | $512.86 | $537.03 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $2,041.74
| Professional | | $1,023.29 | $1,445.44 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $758.58 / $2,570.40
| Facility | | $371.54 | $758.58 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,288.25 / $2,041.74
| Professional | | $1,023.29 | $1,288.25 | $2,041.74 |