- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,621.81 / $8,511.38
| Facility | | $1,584.89 | $1,621.81 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $2,691.53
| Professional | | $1,148.15 | $1,621.81 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,467.37 / $4,168.69
| Professional | | $2,818.38 | $3,467.37 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,691.53 / $4,570.88
| Professional | | $2,187.76 | $2,691.53 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,187.76 / $4,786.30
| Facility | | $1,584.89 | $2,187.76 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,090.30 / $3,715.35
| Professional | | $1,737.80 | $3,090.30 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,090.30 / $3,981.07
| Professional | | $1,737.80 | $3,090.30 | $3,981.07 |