- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,318.26 / $8,511.38
| Facility | | $1,202.26 | $1,318.26 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,318.26 / $1,862.09
| Professional | | $1,122.02 | $1,318.26 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,630.27 / $3,162.28
| Professional | | $2,187.76 | $2,630.27 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,344.23 / $3,801.89
| Professional | | $1,621.81 | $2,344.23 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,862.09 / $3,630.78
| Facility | | $1,202.26 | $1,862.09 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,238.72 / $2,884.03
| Professional | | $1,174.90 | $2,238.72 | $2,884.03 |
- 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 / $2,187.76 / $3,019.95
| Professional | | $1,174.90 | $2,187.76 | $3,019.95 |