- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,623.08 / $1,623.08 / $2,162.35
| Facility | | $1,623.08 | $1,623.08 | $2,162.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.08 / $1,682.10 / $2,567.41
| Professional | | $1,623.08 | $1,682.10 | $2,567.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,100.45 / $3,255.47 / $14,311.68
| Facility | | $3,100.45 | $3,255.47 | $14,311.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,592.81 / $1,718.05 / $2,508.39
| Professional | | $1,592.81 | $1,718.05 | $2,508.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,815.81 / $1,815.81 / $1,815.81
| Facility | | $1,815.81 | $1,815.81 | $1,815.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.54 / $1,325.54 / $1,935.74
| Professional | | $1,325.54 | $1,325.54 | $1,935.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,620.13 / $2,509.52 / $15,138.02
| Facility | | $1,620.13 | $2,509.52 | $15,138.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.10 / $1,546.78 / $3,768.58
| Professional | | $1,201.10 | $1,546.78 | $3,768.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.42 / $1,546.78 / $3,084.86
| Professional | | $1,180.42 | $1,546.78 | $3,084.86 |