- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,380.38 / $6,606.93
| Facility | | $912.01 | $1,380.38 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,230.27 / $1,778.28
| Professional | | $912.01 | $1,230.27 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,344.23 / $6,025.60
| Facility | | $1,905.46 | $2,344.23 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,511.89 / $3,715.35
| Professional | | $1,621.81 | $2,511.89 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $8,511.38
| Facility | | $1,659.59 | $1,659.59 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $3,019.95
| Professional | | $1,412.54 | $1,412.54 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,041.74 / $2,511.89
| Facility | | $1,230.27 | $2,041.74 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,380.38 / $2,187.76
| Professional | | $776.25 | $1,380.38 | $2,187.76 |