- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,076.57 / $1,076.57 / $2,175.13
| Facility | | $1,076.57 | $1,076.57 | $2,175.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.16 / $1,080.54 / $1,168.28
| Professional | | $1,035.16 | $1,080.54 | $1,168.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,718.35 / $1,946.74 / $2,175.13
| Facility | | $1,718.35 | $1,946.74 | $2,175.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,061.08 / $1,181.67 / $1,595.25
| Professional | | $1,061.08 | $1,181.67 | $1,595.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,640.19 / $2,392.64 / $3,262.70
| Facility | | $1,640.19 | $2,392.64 | $3,262.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,848.86 / $2,392.64 / $2,936.43
| Professional | | $1,848.86 | $2,392.64 | $2,936.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,540.39 / $1,540.39 / $2,175.13
| Facility | | $1,540.39 | $1,540.39 | $2,175.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.48 / $1,540.39 / $2,231.26
| Professional | | $1,124.48 | $1,540.39 | $2,231.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $646.26 / $1,036.77 / $1,460.58
| Professional | | $646.26 | $1,036.77 | $1,460.58 |