- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $8,511.38
| Facility | | $1,230.27 | $1,230.27 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,230.27 / $1,819.70
| Professional | | $1,071.52 | $1,230.27 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,691.53 / $3,162.28
| Professional | | $2,137.96 | $2,691.53 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,344.23 / $3,801.89
| Professional | | $1,621.81 | $2,344.23 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,905.46 / $3,715.35
| Facility | | $1,230.27 | $1,905.46 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,137.96 / $2,630.27
| Professional | | $1,122.02 | $2,137.96 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $8,912.51 / $8,912.51
| Facility | | $7,943.28 | $8,912.51 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,137.96 / $3,019.95
| Professional | | $1,122.02 | $2,137.96 | $3,019.95 |