- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,044.14 / $1,045.15 / $1,045.15
| Facility | | $1,044.14 | $1,045.15 | $1,045.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.15 / $1,045.15 / $1,795.95
| Professional | | $1,045.15 | $1,045.15 | $1,795.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,571.97 / $12,829.58 / $17,259.89
| Facility | | $10,571.97 | $12,829.58 | $17,259.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.15 / $1,045.15 / $1,045.15
| Professional | | $1,045.15 | $1,045.15 | $1,045.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,045.15 / $1,045.15 / $1,045.15
| Facility | | $1,045.15 | $1,045.15 | $1,045.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.15 / $1,045.15 / $1,045.15
| Professional | | $1,045.15 | $1,045.15 | $1,045.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,043.55 / $1,043.55 / $1,273.13
| Facility | | $1,043.55 | $1,043.55 | $1,273.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.17 / $1,045.15 / $1,045.15
| Professional | | $1,027.17 | $1,045.15 | $1,045.15 |