- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,174.90 / $8,511.38
| Facility | | $1,122.02 | $1,174.90 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,202.26 / $1,737.80
| Professional | | $1,122.02 | $1,202.26 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,570.40 / $3,019.95
| Professional | | $2,041.74 | $2,570.40 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,187.76 / $3,548.13
| Professional | | $1,513.56 | $2,187.76 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,737.80 / $3,548.13
| Facility | | $1,202.26 | $1,737.80 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,187.76 / $2,570.40
| Professional | | $1,202.26 | $2,187.76 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,187.76 / $2,951.21
| Professional | | $1,202.26 | $2,187.76 | $2,951.21 |