- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,258.93 / $8,511.38
| Facility | | $1,122.02 | $1,258.93 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,258.93 / $1,737.80
| Professional | | $1,047.13 | $1,258.93 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,511.89 / $2,951.21
| Professional | | $2,041.74 | $2,511.89 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,238.72 / $3,630.78
| Professional | | $1,513.56 | $2,238.72 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,737.80 / $3,388.44
| Facility | | $1,122.02 | $1,737.80 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,089.30 / $2,691.53
| Professional | | $1,174.90 | $2,089.30 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $8,912.51 / $8,912.51
| Facility | | $7,943.28 | $8,912.51 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,089.30 / $2,884.03
| Professional | | $1,174.90 | $2,089.30 | $2,884.03 |