- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,029.06 / $3,172.50 / $6,929.82
| Facility | | $1,029.06 | $3,172.50 | $6,929.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.87 / $1,029.07 / $1,053.85
| Professional | | $991.87 | $1,029.07 | $1,053.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.52 / $1,204.71 / $1,307.00
| Professional | | $1,136.52 | $1,204.71 | $1,307.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,053.85 / $1,053.85 / $1,053.85
| Facility | | $1,053.85 | $1,053.85 | $1,053.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.85 / $1,053.85 / $1,053.85
| Professional | | $1,053.85 | $1,053.85 | $1,053.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,177.84 / $4,104.20 / $5,155.00
| Facility | | $1,177.84 | $4,104.20 | $5,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,487.04 / $4,711.39 / $5,313.60
| Professional | | $4,487.04 | $4,711.39 | $5,313.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,701.15 / $1,701.15 / $1,701.15
| Facility | | $1,701.15 | $1,701.15 | $1,701.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.20 / $1,033.20 / $1,033.20
| Professional | | $1,002.20 | $1,033.20 | $1,033.20 |