- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,047.13 / $2,089.30
| Facility | | $812.83 | $1,047.13 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,047.13 / $1,621.81
| Professional | | $794.33 | $1,047.13 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $4,365.16
| Facility | | $812.83 | $1,096.48 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,096.48 / $2,398.83
| Professional | | $1,047.13 | $1,096.48 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $8,128.31
| Facility | | $1,380.38 | $1,380.38 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $3,162.28
| Professional | | $1,023.29 | $1,023.29 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,174.90 / $2,398.83
| Facility | | $691.83 | $1,174.90 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $933.25 / $1,548.82
| Professional | | $691.83 | $933.25 | $1,548.82 |