- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,230.27 / $8,511.38
| Facility | | $1,148.15 | $1,230.27 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,258.93 / $1,778.28
| Professional | | $1,148.15 | $1,258.93 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,630.27 / $3,162.28
| Professional | | $2,137.96 | $2,630.27 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,290.87 / $3,715.35
| Professional | | $1,584.89 | $2,290.87 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,819.70 / $3,715.35
| Facility | | $1,230.27 | $1,819.70 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,238.72 / $2,691.53
| Professional | | $1,230.27 | $2,238.72 | $2,691.53 |
- 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
- $1,230.27 / $2,238.72 / $3,090.30
| Professional | | $1,230.27 | $2,238.72 | $3,090.30 |