- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,513.56 / $8,511.38
| Facility | | $1,445.44 | $1,513.56 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,513.56 / $3,715.35
| Professional | | $1,380.38 | $1,513.56 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,548.13 / $4,168.69
| Professional | | $2,884.03 | $3,548.13 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,818.38 / $4,570.88
| Professional | | $1,659.59 | $2,818.38 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,995.26 / $2,754.23
| Facility | | $1,513.56 | $1,995.26 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,754.23 / $11,220.18
| Professional | | $1,445.44 | $2,754.23 | $11,220.18 |
- 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 / $2,754.23 / $3,801.89
| Professional | | $1,412.54 | $2,754.23 | $3,801.89 |