- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,479.11 / $8,511.38
| Facility | | $1,348.96 | $1,479.11 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,659.59 / $3,090.30
| Professional | | $1,348.96 | $1,659.59 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,311.31 / $3,981.07
| Professional | | $2,818.38 | $3,311.31 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,754.23 / $4,168.69
| Professional | | $1,584.89 | $2,754.23 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,041.74 / $3,235.94
| Facility | | $1,479.11 | $2,041.74 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,398.83 / $10,964.78
| Professional | | $1,380.38 | $2,398.83 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,819.70 / $2,041.74
| Facility | | $676.08 | $1,819.70 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,041.74 / $3,235.94
| Professional | | $1,348.96 | $2,041.74 | $3,235.94 |