- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,202.26 / $8,511.38
| Facility | | $1,122.02 | $1,202.26 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,230.27 / $1,737.80
| Professional | | $1,122.02 | $1,230.27 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,570.40 / $3,019.95
| Professional | | $2,089.30 | $2,570.40 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,238.72 / $3,548.13
| Professional | | $1,548.82 | $2,238.72 | $3,548.13 |
- 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 / $2,137.96 / $2,570.40
| Professional | | $1,202.26 | $2,137.96 | $2,570.40 |
- 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 / $2,137.96 / $3,019.95
| Professional | | $1,202.26 | $2,137.96 | $3,019.95 |