- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,445.44 / $8,511.38
| Facility | | $1,380.38 | $1,445.44 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,445.44 / $2,137.96
| Professional | | $1,318.26 | $1,445.44 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,388.44 / $3,981.07
| Professional | | $2,754.23 | $3,388.44 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,691.53 / $4,677.35
| Professional | | $1,949.84 | $2,691.53 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,137.96 / $4,365.16
| Facility | | $1,445.44 | $2,137.96 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,630.27 / $3,090.30
| Professional | | $1,412.54 | $2,630.27 | $3,090.30 |
- 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
- $1,412.54 / $2,630.27 / $3,467.37
| Professional | | $1,412.54 | $2,630.27 | $3,467.37 |