- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,887.97 / $1,887.97 / $2,265.56
| Facility | | $1,887.97 | $1,887.97 | $2,265.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.42 / $1,465.01 / $1,887.97
| Professional | | $1,281.42 | $1,465.01 | $1,887.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,353.01 / $3,353.01 / $3,974.66
| Facility | | $3,353.01 | $3,353.01 | $3,974.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,696.36 / $1,696.36 / $1,780.13
| Professional | | $1,696.36 | $1,696.36 | $1,780.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.07 / $1,743.07 / $1,743.07
| Facility | | $1,743.07 | $1,743.07 | $1,743.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.44 / $1,272.44 / $1,743.07
| Professional | | $1,272.44 | $1,272.44 | $1,743.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,714.77 / $2,714.77 / $8,379.14
| Professional | | $2,714.77 | $2,714.77 | $8,379.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.18 / $1,672.78 / $2,096.37
| Professional | | $1,115.18 | $1,672.78 | $2,096.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.29 / $2,762.42 / $3,515.81
| Professional | | $2,511.29 | $2,762.42 | $3,515.81 |