- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,594.65 / $1,803.02 / $5,804.53
| Facility | | $1,594.65 | $1,803.02 | $5,804.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,594.65 / $1,658.44 / $2,019.89
| Professional | | $1,594.65 | $1,658.44 | $2,019.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.61 / $2,806.58 / $4,188.60
| Professional | | $1,105.61 | $2,806.58 | $4,188.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,423.80 / $4,580.72 / $7,591.38
| Facility | | $1,423.80 | $4,580.72 | $7,591.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,126.19 / $2,126.19 / $10,248.28
| Professional | | $2,126.19 | $2,126.19 | $10,248.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,699.59 / $10,099.45 / $10,099.45
| Facility | | $3,699.59 | $10,099.45 | $10,099.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,588.48 / $10,588.48 / $15,946.50
| Professional | | $10,588.48 | $10,588.48 | $15,946.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,657.75 / $2,657.75 / $2,657.75
| Facility | | $2,657.75 | $2,657.75 | $2,657.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.00 / $1,275.72 / $2,126.19
| Professional | | $893.00 | $1,275.72 | $2,126.19 |