- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,107.16 / $1,687.74 / $2,025.28
| Facility | | $1,107.16 | $1,687.74 | $2,025.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.64 / $1,107.16 / $1,147.66
| Professional | | $1,012.64 | $1,107.16 | $1,147.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,485.21 / $2,025.29 / $2,362.83
| Facility | | $1,485.21 | $2,025.29 | $2,362.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,620.23 / $1,620.23 / $1,822.76
| Professional | | $1,620.23 | $1,620.23 | $1,822.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,097.03 / $1,620.23 / $4,050.22
| Facility | | $1,097.03 | $1,620.23 | $4,050.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.64 / $1,939.55 / $6,507.92
| Professional | | $1,551.64 | $1,939.55 | $6,507.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,248.81 / $6,248.81 / $6,248.81
| Facility | | $6,248.81 | $6,248.81 | $6,248.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.11 / $810.11 / $810.11
| Professional | | $810.11 | $810.11 | $810.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.08 / $607.59 / $1,822.76
| Professional | | $567.08 | $607.59 | $1,822.76 |