- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $3,019.95
| Facility | | $1,230.27 | $1,584.89 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,659.59 / $2,570.40
| Professional | | $1,230.27 | $1,659.59 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,778.28 / $6,760.83
| Facility | | $1,288.25 | $1,778.28 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,698.24 / $3,715.35
| Professional | | $1,513.56 | $1,698.24 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $10,964.78
| Facility | | $2,041.74 | $2,041.74 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $4,168.69
| Professional | | $1,513.56 | $1,513.56 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,137.96 / $3,890.45
| Facility | | $1,862.09 | $2,137.96 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $2,398.83
| Professional | | $1,122.02 | $1,513.56 | $2,398.83 |