- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,258.93 / $8,511.38
| Facility | | $1,148.15 | $1,258.93 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,380.38 / $2,570.40
| Professional | | $1,148.15 | $1,380.38 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,754.23 / $3,311.31
| Professional | | $2,344.23 | $2,754.23 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,290.87 / $3,548.13
| Professional | | $1,380.38 | $2,290.87 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,737.80 / $3,235.94
| Facility | | $1,258.93 | $1,737.80 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,995.26 / $9,772.37
| Professional | | $1,148.15 | $1,995.26 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,995.26 / $3,630.78
| Facility | | $1,819.70 | $1,995.26 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,737.80 / $2,754.23
| Professional | | $1,122.02 | $1,737.80 | $2,754.23 |