- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,072.91 / $1,072.91 / $1,072.91
| Facility | | $1,072.91 | $1,072.91 | $1,072.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.00 / $1,096.13 / $1,351.36
| Professional | | $794.00 | $1,096.13 | $1,351.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.29 / $456.40 / $500.39
| Professional | | $375.29 | $456.40 | $500.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.72 / $2,294.63 / $3,585.76
| Professional | | $1,150.72 | $2,294.63 | $3,585.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,072.91 / $1,579.08 / $1,979.78
| Facility | | $1,072.91 | $1,579.08 | $1,979.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,504.10 / $3,213.29 / $6,610.61
| Professional | | $1,504.10 | $3,213.29 | $6,610.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.66 / $2,489.46 / $3,689.28
| Professional | | $1,635.66 | $2,489.46 | $3,689.28 |