- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,698.24 / $2,454.71
| Facility | | $1,230.27 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,548.82 / $1,995.26
| Professional | | $1,318.26 | $1,548.82 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,511.89
| Facility | | $1,819.70 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $2,187.76
| Professional | | $1,659.59 | $1,659.59 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,995.26 / $2,818.38
| Professional | | $1,202.26 | $1,995.26 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,570.40 / $5,623.41
| Facility | | $1,230.27 | $2,570.40 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,659.59 / $2,691.53
| Professional | | $1,230.27 | $1,659.59 | $2,691.53 |