- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,137.96 / $4,466.84
| Facility | | $977.24 | $2,137.96 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,258.93 / $3,630.78
| Professional | | $1,096.48 | $1,258.93 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $3,162.28
| Facility | | $1,122.02 | $1,513.56 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,202.26 / $1,548.82
| Professional | | $1,096.48 | $1,202.26 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $2,754.23
| Facility | | $1,230.27 | $1,230.27 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,230.27 / $1,479.11
| Professional | | $1,148.15 | $1,230.27 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,398.83 / $3,890.45
| Facility | | $1,445.44 | $2,398.83 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,258.93 / $1,513.56
| Professional | | $1,202.26 | $1,258.93 | $1,513.56 |