- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,646.91 / $8,646.91 / $9,508.37
| Facility | | $8,646.91 | $8,646.91 | $9,508.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,269.08 / $1,488.76 / $1,811.63
| Professional | | $1,269.08 | $1,488.76 | $1,811.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,497.70 / $1,938.21 / $2,712.56
| Professional | | $1,497.70 | $1,938.21 | $2,712.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.40 / $2,173.94 / $3,136.28
| Professional | | $1,441.40 | $2,173.94 | $3,136.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,768.34 / $2,045.97 / $3,138.63
| Professional | | $1,768.34 | $2,045.97 | $3,138.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,646.91 / $8,646.91 / $9,508.37
| Facility | | $8,646.91 | $8,646.91 | $9,508.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,269.08 / $1,493.80 / $1,811.63
| Professional | | $1,269.08 | $1,493.80 | $1,811.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,376.84 / $2,019.09 / $2,862.94
| Professional | | $1,376.84 | $2,019.09 | $2,862.94 |