- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,258.93 / $8,511.38
| Facility | | $1,174.90 | $1,258.93 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,288.25 / $1,621.81
| Professional | | $1,174.90 | $1,288.25 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,818.38 / $3,311.31
| Professional | | $2,290.87 | $2,818.38 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,454.71 / $3,890.45
| Professional | | $1,659.59 | $2,454.71 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,089.30 / $3,801.89
| Facility | | $1,258.93 | $2,089.30 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,290.87 / $2,754.23
| Professional | | $1,288.25 | $2,290.87 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,782.79 / $19,952.62 / $19,952.62
| Facility | | $17,782.79 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,290.87 / $3,162.28
| Professional | | $1,288.25 | $2,290.87 | $3,162.28 |