- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,148.15 / $8,511.38
| Facility | | $1,047.13 | $1,148.15 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,174.90 / $1,479.11
| Professional | | $1,047.13 | $1,174.90 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,630.27 / $3,090.30
| Professional | | $2,089.30 | $2,630.27 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,238.72 / $3,630.78
| Professional | | $1,513.56 | $2,238.72 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,905.46 / $3,467.37
| Facility | | $1,148.15 | $1,905.46 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,089.30 / $2,511.89
| Professional | | $1,202.26 | $2,089.30 | $2,511.89 |
- 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 / $2,089.30 / $2,884.03
| Professional | | $1,202.26 | $2,089.30 | $2,884.03 |