- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,096.48 / $8,511.38
| Facility | | $1,047.13 | $1,096.48 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,122.02 / $1,621.81
| Professional | | $1,047.13 | $1,122.02 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,344.23 / $2,818.38
| Professional | | $1,905.46 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,041.74 / $3,311.31
| Professional | | $1,412.54 | $2,041.74 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,621.81 / $3,311.31
| Facility | | $1,096.48 | $1,621.81 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,041.74 / $2,398.83
| Professional | | $1,096.48 | $2,041.74 | $2,398.83 |
- 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
- $1,096.48 / $2,041.74 / $2,754.23
| Professional | | $1,096.48 | $2,041.74 | $2,754.23 |