- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,554.57 / $3,225.73 / $4,259.52
| Facility | | $1,554.57 | $3,225.73 | $4,259.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.23 / $1,554.57 / $1,651.73
| Professional | | $1,292.23 | $1,554.57 | $1,651.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,476.55 / $1,894.64 / $5,101.13
| Facility | | $1,476.55 | $1,894.64 | $5,101.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,554.57 / $1,943.21 / $2,914.82
| Facility | | $1,554.57 | $1,943.21 | $2,914.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.08 / $1,263.08 / $1,943.21
| Professional | | $1,263.08 | $1,263.08 | $1,943.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,943.21 / $2,973.11 / $3,721.25
| Professional | | $1,943.21 | $2,973.11 | $3,721.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.61 / $1,165.93 / $2,914.82
| Professional | | $971.61 | $1,165.93 | $2,914.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,381.19 / $9,230.25 / $9,230.25
| Facility | | $3,381.19 | $9,230.25 | $9,230.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,677.19 / $9,677.19 / $14,574.08
| Professional | | $9,677.19 | $9,677.19 | $14,574.08 |