- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $896.18 / $896.18 / $2,417.11
| Facility | | $896.18 | $896.18 | $2,417.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.63 / $1,214.63 / $1,336.09
| Professional | | $1,214.63 | $1,214.63 | $1,336.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.34 / $683.91 / $1,064.25
| Facility | | $437.34 | $683.91 | $1,064.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,238.93 / $1,238.93 / $1,238.93
| Facility | | $1,238.93 | $1,238.93 | $1,238.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.93 / $1,238.93 / $1,238.93
| Professional | | $1,238.93 | $1,238.93 | $1,238.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,090.76 / $1,322.04 / $5,205.56
| Facility | | $1,090.76 | $1,322.04 | $5,205.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.63 / $1,214.63 / $1,214.63
| Professional | | $1,214.63 | $1,214.63 | $1,214.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.63 / $1,214.63 / $1,214.63
| Professional | | $1,214.63 | $1,214.63 | $1,214.63 |