- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,202.26 / $8,511.38
| Facility | | $1,148.15 | $1,202.26 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,230.27 / $1,778.28
| Professional | | $1,148.15 | $1,230.27 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,570.40 / $3,090.30
| Professional | | $2,089.30 | $2,570.40 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,238.72 / $3,630.78
| Professional | | $1,548.82 | $2,238.72 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,778.28 / $3,630.78
| Facility | | $1,202.26 | $1,778.28 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,187.76 / $2,630.27
| Professional | | $1,202.26 | $2,187.76 | $2,630.27 |
- 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
- $1,202.26 / $2,187.76 / $3,019.95
| Professional | | $1,202.26 | $2,187.76 | $3,019.95 |