- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,089.30 / $2,344.23
| Facility | | $1,737.80 | $2,089.30 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,548.82 / $2,344.23
| Professional | | $1,122.02 | $1,548.82 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,981.07
| Facility | | $2,884.03 | $2,884.03 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,659.59 / $2,187.76
| Professional | | $1,288.25 | $1,659.59 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,238.72 / $2,951.21
| Professional | | $1,445.44 | $2,238.72 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,890.45 / $7,762.47
| Facility | | $1,548.82 | $3,890.45 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,737.80 / $2,818.38
| Professional | | $1,258.93 | $1,737.80 | $2,818.38 |