- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,318.26 / $8,511.38
| Facility | | $1,174.90 | $1,318.26 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,318.26 / $1,659.59
| Professional | | $1,174.90 | $1,318.26 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,818.38 / $3,388.44
| Professional | | $2,290.87 | $2,818.38 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,398.83 / $3,890.45
| Professional | | $1,698.24 | $2,398.83 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,089.30 / $3,890.45
| Facility | | $1,318.26 | $2,089.30 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,344.23 / $2,818.38
| Professional | | $1,380.38 | $2,344.23 | $2,818.38 |
- 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
- $1,380.38 / $2,344.23 / $3,235.94
| Professional | | $1,380.38 | $2,344.23 | $3,235.94 |