- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,258.93 / $19,498.45
| Facility | | $1,122.02 | $1,258.93 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,318.26 / $4,677.35
| Professional | | $1,122.02 | $1,318.26 | $4,677.35 |
- 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 / $2,290.87 / $3,715.35
| Professional | | $1,621.81 | $2,290.87 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,995.26 / $3,715.35
| Facility | | $1,258.93 | $1,995.26 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,187.76 / $2,691.53
| Professional | | $1,318.26 | $2,187.76 | $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
- $1,318.26 / $2,187.76 / $3,090.30
| Professional | | $1,318.26 | $2,187.76 | $3,090.30 |