- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,621.81 / $2,754.23
| Facility | | $1,258.93 | $1,621.81 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,621.81 / $2,754.23
| Professional | | $1,230.27 | $1,621.81 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,737.80 / $6,309.57
| Facility | | $1,258.93 | $1,737.80 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,737.80 / $3,548.13
| Professional | | $1,659.59 | $1,737.80 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $12,302.69
| Facility | | $1,737.80 | $1,737.80 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $4,786.30
| Professional | | $1,258.93 | $1,258.93 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,089.30 / $3,801.89
| Facility | | $1,445.44 | $2,089.30 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,584.89 / $2,344.23
| Professional | | $1,122.02 | $1,584.89 | $2,344.23 |