- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,202.26 / $8,511.38
| Facility | | $1,096.48 | $1,202.26 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,230.27 / $1,548.82
| Professional | | $1,096.48 | $1,230.27 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,630.27 / $3,090.30
| Professional | | $2,137.96 | $2,630.27 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,238.72 / $3,630.78
| Professional | | $1,584.89 | $2,238.72 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,949.84 / $3,630.78
| Facility | | $1,202.26 | $1,949.84 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,137.96 / $2,630.27
| Professional | | $1,288.25 | $2,137.96 | $2,630.27 |
- 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
- $1,288.25 / $2,137.96 / $3,019.95
| Professional | | $1,288.25 | $2,137.96 | $3,019.95 |