- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,318.26 / $8,511.38
| Facility | | $1,258.93 | $1,318.26 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,318.26 / $3,235.94
| Professional | | $1,071.52 | $1,318.26 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,090.30 / $3,630.78
| Professional | | $2,454.71 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,454.71 / $3,981.07
| Professional | | $1,479.11 | $2,454.71 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,737.80 / $3,890.45
| Facility | | $1,318.26 | $1,737.80 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,238.72 / $9,772.37
| Professional | | $1,258.93 | $2,238.72 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $6,025.60
| Facility | | $1,819.70 | $2,041.74 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,344.23 / $3,311.31
| Professional | | $1,258.93 | $2,344.23 | $3,311.31 |